Clinical Prior Authorization Appeal Specialist

SCOPE / GENERAL PURPOSE OF JOB:

Responsible for all aspects of the prior authorization appeal process. Must ensure the proton insurance prior authorization denials are appealed timely and accurately for RC Billings’ proton clients. Must be able to locate clinical documents supporting proton therapy medical necessity for specific diagnosis.  Must have the ability to compose detailed letters of medical necessity for appeal submission. Must be able to perform comparative plans, IMRT vs. Proton therapy plan, and be able to effectively communicate and deliver clinical peer to peer reviews with insurance payers. Must have and maintain strong radiation oncology coding knowledge.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

  • Demonstrates thorough understanding of the Radiation Oncology coding compliant with Federal and State regulations and RC Billing policy and procedures.
  • Collecting all the necessary documentation for clients as well as contacting the client for additional information and completion of the required prior authorization appeal.
  • Complete timely and accurate identification and submission of prior, retro authorization requests to payers when applicable.
  • Interacts with clients, insurance companies, patients and sales representatives, as necessary, to perform prior authorization appeals.
  • Maintains strong working knowledge of the clients EMR systems, ARIA and MOSAIQ.
  • Demonstrates extensive knowledge of Proton planning.
  • Responsible for documenting account activity, updating patient and claim information and demonstrates proficiency with the billing system to ensure all functionalities are utilized for the most efficient processing of claims and identifies prior authorization trends and/or issues resulting in delayed claims processing.
  • Accurately models comparative planning for clients.
  • Ensures strong working knowledge of planning system software’s including Eclipse, Raystation and Elekta XiO.
  • Will professionally perform clinical peer to peer reviews with payers on behalf of RC Billing clients.
  • Updates job knowledge by participating in educational opportunities. Ensures strong communication with RCB Cedar Park management team.
  • Ensures compliance with RC Billing Reimbursement Policies and Procedures to maximize efficiency
  • Ensures compliance with appropriate industry regulations and State and Federal regulations.
  • Maintains working knowledge of applicable laws and regulations as they relate to assigned responsibilities.
  • Maintains confidentiality of all information related to patients, medical staff, finances and cost effective healthcare delivery issues.
  • Demonstrates the ability to work well with peers while ensuring a strong cohesive team.
  • Must be able to complete work in the assigned Cedar Park corporate office.
  • All other duties as assigned.

EDUCATION AND/OR EXPERIENCE:

  • Bachelor’s degree in a related field is required.
  • Minimum seven (7) years’ experience as a dosimetrist.
  • Certification through the Medical Dosimetrist Certification Board (MDCB)
  • Must have payer relations experience in a healthcare environment.

QUALIFICATIONS:

  • Knowledge of organization policies and procedures. 
  • Knowledge of healthcare administration principals. 
  • Knowledge of front office procedures. 
  • Knowledge of insurance agency operating procedures and practices. 
  • Skills in exercising initiative, judgment, discretion, decision–making and organizational skills to achieve business unit objectives. 
  • Skills in identifying and resolving problems. 
  • Ability to communicate effectively and professionally. 
  • Ability to establish and maintain effective professional working relationships with all employees and clients.  
  • Advanced knowledge of radiation oncology coding. 
  • Strong working knowledge of ARIA and MOSAIQ.
  • Strong working knowledge of planning systems such as Eclipse, Raystation and Elekta XiO required.
  • Ability to communicate effectively and professionally orally and in writing.

CERTIFICATIONS / LICENSURES / CREDENTIALS:  CPC or AAPC certification preferred but not required.

SUPERVISORY RESPONSIBILITIES:  None

PHYSICAL DEMANDS:

The physical demands described are representative of those that must be met by an employee to successfully perform the essential functions of this position.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.  This position requires full range of body motion including manual and finger dexterity and eye-hand coordination.  The position additionally requires standing/sitting for extensive periods of time.  Occasional lifting and carrying items weighing up to forty (40) pounds may be required.  Requires corrected vision and hearing to normal range.

WORK ENVIRONMENT:

The work environment characteristics described are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Work is performed in an office environment involving frequent interaction with staff, clients and the general public.

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