All the benefits and perks you need for you and your family:

• Benefits from Day One
• Paid Days Off from Day One
• Student Loan Repayment Program
• Career Development
• Whole Person Wellbeing Resources
• Mental Health Resources and Support
• Pet Insurance*
• Debt-free Education* (Certifications and Degrees without out-of-pocket tuition expense)

Our promise to you:

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Schedule: Full Time/Part Time 

Shift: Day Shift

Location: 

The role you’ll contribute:

 The Pre-Access Infusion Benefits and Authorization Specialist, under general supervision, maintains performance standards appropriate to area by obtaining account benefits and/or verifying authorizations are in place for all chemotherapy regimens and treatments, and meeting standards established by leadership for all patient services. Meets or exceeds department audit accuracy and productivity standard goal. Uses utmost caution that obtained benefits, authorizations, and/or pre-certifications are accurate according to the actual test, and procedure or registration being performed. Adheres to AdventHealth Corporate Compliance Plan and to all rules and regulations of all applicable local, state and federal agencies and accrediting bodies. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.

The value you’ll bring to the team:

• Responsible for review of chemotherapy regimen/treatment orders and determines insurance benefits and authorization requirements. Reviews clinical data such as patient pathology reports, scans, laboratory results, prior treatments, matching against insurance payor and/or National Comprehensive Cancer Network (NCCN) guidelines. Ensures specified medical terms, diagnosis, medication codes and supporting clinical documentations are met. Utilization review to facilitate the sending of clinical information in support of the authorization to payor or third-party administrators, as assigned.
• Reviews medical records in detail to confirm the treatment is supported by approved medical studies by reputable oncology/hematology studies. Stays current on payer preference for biosimilar drugs available. Ensures patient orders are changed accordingly if biosimilar drug is preferred. Ensures that each treatment is coded, reviewed, and financially cleared based on the patient insurance requirements.
• Verifies medical necessity in accordance with Centers for Medicare & Medicaid Services (CMS) standards by reviewing guidelines and communicates relevant coverage/eligibility information to the patient. Alerts physician offices to issues with verifying insurance. Responsible for communicating to service line partners of situations where medical necessity is not met to include review of journal articles, compendia and/or peer review to justify medical necessity approval
• Reviews clinical records when following up on authorization request directly with a payor. Escalates peer to peer (insurance company physician requests to speak to ordering physician) requests to physician offices and assists in scheduling peer to peer requests with the office and the payer to ensure an authorization decision is made prior to date of service.
• Obtains initial and subsequent pre-authorization for chemotherapy treatments, as well as research protocols, on all new and existing patients and notes approvals in the electronic medical record. Uploads treatment supporting documentation packet to the electronic medical record for Revenue Cycle billing and coding teams.
• Contacts insurance companies by phone, fax, online portal, and other resources to obtain and verify insurance eligibility and benefits and determine extent of coverage within established timeframe before scheduled appointments and during or after care for unscheduled patients
• Obtains pre-authorizations from third-party payers in accordance with payer requirements and within established timeframe before scheduled appointments and during or after care for unscheduled patients. Accurately enters required authorization information in AdventHealth systems to include length of authorization, total number of visits, and/or units of medication. Convert orders and dosage to ensure the proper authorization is requested and approved, based on the units the payer has given.
• Maintains a close working relationship with clinical partners and physician offices to ensure continual open communication between clinical, ancillary, and Patient Access & Patient Financial Services departments by monitoring team e-mail boxes and phone calls to follow up on issues timely. Responsible for communicating to service line partners of situations where rescheduling is necessary, due to lack of authorization or limited benefits.
• Obtains PCP referrals when applicable
• Alerts physician offices / ancillary departments to issues with obtaining pre-authorizations. Conducts diligent follow-up on missing or incomplete pre-authorizations with third-party payers to minimize authorization related denials through phone calls, emails, faxes, and payer websites, updating documentation as needed
• Corrects demographic, insurance, or authorization related errors and pre-bill edits
• Meets or exceeds accuracy standards and ensures integrity of patient accounts by working error reports as requested by leadership and entering appropriate and accurate data
• Proactively seeks assistance to improve any responsibilities assigned to their role
• Provides timely and continual coverage of assigned work area in order to offer prompt patient service and availability for all clinical partner registration needs. Arranges relief coverage during extended time away from assigned registration area
• Meets and exceeds productivity standards determined by department leadership
• Meets attendance and punctuality requirements. Maintains schedule flexibility to meet department needs. Exhibits effective time management skills by monitoring time and attendance to limit use of unauthorized overtime 
• Actively attends department meetings and promotes positive dialogue within the team
• Monitors compliance with local facility and AdventHealth policies and procedures
• Performs other duties as assigned

Qualifications

The expertise and experiences you’ll need to succeed:

Required:

• Mature judgement in dealing with patients, physicians, and insurance representatives
• Intermediate knowledge of Microsoft programs and familiarity with database programs
• Ability to operate general office machines such as computer, fax machine, printer, and scanner
• Ability to effectively learn and perform multiple tasks, and organize work in a systematic and efficient fashion
• Ability to communicate professionally and effectively, both verbally and written
• Ability to adapt in ever changing healthcare environment
• Ability to follow complex instructions and procedures, with a close attention to detail
• Adheres to government guidelines such as CMS, EMTALA, and HIPAA and AdventHealth corporate policies
• Exceptional customer service skills
• Advanced understanding of insurance knowledge and benefits
• Advanced understanding of hospital electronic medical report (EMR) system
• Basic medical terminology
• Must be able to read, write, and speak conversational English

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location.

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