Under the general supervision of the Administrative Manager and per the established policies and procedures, the Insurance specialist is responsible for overseeing the Radiation Oncology authorization process. Working very closely with nurses, physicians and other clinical staff members to ensure a quality-based, customer-oriented flow of work throughout the practice. Serves as the subject matter expert in radiation oncology authorizations, and is the resource person for support staff, intake manager and all clinical staff.
Understands all insurance medical policies, including managed care plans, HMO's and unusual coverage. Determines eligibility and obtains Prior authorizations and Pre-determination from third party payers for all types of radiation procedures (i.e. Proton, IMRT, VMAT, SRS, SBRT, 3D). Requires understanding of coordination of benefits, and references medical policies for coverage. Provides information to patients regarding eligibility for radiation services.
Responsible for locating medical policy on insurance website and determining eligibility using external resources
Responsible for providing necessary information as required by third party payer, and completing required pre-authorization forms (payer specific)
Will set up peer to peer review with the physician and third party, documenting outcome
Responsible for obtaining a letter of medical necessity for radiation treatment from the physician
Informs patient and physician of any potential problems with coverage or authorization prior to scheduling appointment
Responsible for obtaining all authorizations, in an appropriate time frame. Must have great time management skills as well as great follow through to see the authorization from start to finish
Will require an understanding of radiation oncology CPT codes for treatment authorization, as well as ICD10 codes for diagnosis
Will be required to work very independently and function at a very high level in order to complete pre-auth and pre-D form submission
Attends Proton rounds every Tuesday and communicates to physicians any potential insurance barriers
Responsible for updating "Whiteboard" with authorization information
Attends weekly managed care meetings
Will work to obtain an estimate of charges for the international office or at any patient request
Maintains excellent records (electronic and otherwise) of all referrals and inquiries.
Participates in an open line of communication with the team (adult and Pedi) to collaborate, exchange information and review patient scheduling status
May be required to provide clinical documentation for insurance review
Will be responsible for working the RO Insurance mailbox
Responsible for working any patient denial and appeal
Responsible for working Epic work queues
Responsible for accuracy and quality of individual work assignment, and a willingness to assist other team members validating the importance and value of team success
Qualifications
QUALIFICATIONS:
Associates Degree or higher preferred
Minimum of 5 years of healthcare experience
Knowledge of third party payers a plus
Knowledge of ICD10 and CPT coding a plus
Must have basic knowledge of Anatomy and Physiology
Medical terminology and medical coding knowledge desired.
Excellent customer service and communication skills
Good organizational skills required to handle multiple tasks in a busy environment
Basic knowledge of Outlook, word and excel. Will train in department system.
Ability of work independently and prioritize work.
Excellent customer service and communication skills
Good organizational skills required to handle multiple tasks in a busy environment
Willingness to continually learn and grow as a member of a Team and Department
The right candidate must have a positive attitude, quick mind, and thrive with working under strict time lines.
EEO Statement
Massachusetts General Hospital is an Affirmative Action Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.
