Job Description
Description
Serves as the primary clinical resource in the PreCertification Department for the handling of complex authorization issues.
Responsible for clinically assessing all adverse determinations made by insurers through all levels of the Pre-Service Administrative appeals process.
Supports the Patient Access team (both management and staff) to ensure precertification / authorization issues are investigated and handled expeditious and thoughtfully from an administrative, technical and clinical perspectives.
Serves as the primary liaison between the Precertification Department and staff Physicians in regard to authorization
issues. Supports the Infusion, Radiation Therapy, Surgical, and Diagnostic Imaging Precertification Teams. Responsible for reviewing financial / insurance information obtained during the financial clearance process to determine payer requirements are met by obtaining the appropriate referrals, pre-certification / authorization for payers in order to optimize reimbursement and avoid payment penalties.
Education
Other : Graduate of an accredited RN program (Required)
Bachelors Degree : Nursing or other clinical health care field (Preferred)
Experience
3 Years recent experience with Utilization Review in a hospital or in insurance company setting (Required)
2 Years experience in oncological authorization / precertification (Preferred)
General Experience in working with utilization review standards (Preferred)
License / Certifications
RN-LIC - PA Registered Nurse License (Required)
CPUR - Cert Prof Utilization Review (Preferred)
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