OneOncology is positioning community oncologists to drive the future of medical care through a patient-centric, physician-driven, and technology-powered model to help improve the lives of everyone living with cancer and other diseases. Our team is bringing together leaders to the market place to help drive OneOncology’s mission and vision.

Why join us? This is an exciting time to join OneOncology. Our values-driven culture reflects our startup enthusiasm supported by industry leaders in oncology, urology, technology, and finance. We are looking for talented and highly-motivated individuals who demonstrate a natural desire to improve and build new processes that support the meaningful work of independent physicians and the patients they serve.

Job Description:

The Sr. Authorization Specialist will be responsible for obtaining pre-authorization for proton therapy treatments for patients. The individual will need to have expertise in the areas of appeals, ERISA regulations, and insurance reimbursement processes, as proton therapy is commonly denied by insurance providers. The successful candidate will work closely with patients, physicians, and insurance companies to ensure that necessary pre-authorization and appeals are completed in a timely and accurate manner. This specialized role will be key to the success of the Proton center and will drive future revenue and performance.

ESSENTIAL FUNCTIONS:

• Verify patient’s insurance coverage and benefits, including any deductibles, copays, and coinsurance.
• Accurately communicate the patient’s coverage and benefits with the Proton Financial Counselor.
• Review and interpret insurance policies, including ERISA regulations, to ensure compliance with requirements for Proton therapy treatments.
• Obtain prior authorization for Proton therapy treatments, as required, through the patient’s insurance carrier or appropriate third-party vendor.
• Provide guidance to the Proton center’s clinical team so that all requirements to support the medical necessity of ordered services is clearly documented in the patient’s Electronic Medical Record.
• Provide all necessary clinical documentation with prior authorization requests to support the medical necessity of Proton therapy treatments, as indicated by payer policies and guidelines.
• Review and submit, if required, Cancer Registry documentation for auth approval.
• Monitor and track the progress of all prior authorization requests.
• Submit initial appeals for pre-service authorization denials per payer guidelines.
• Maintain accurate and up-to-date records of all prior authorization and appeal follow-up activities in the Electronic Medical Record and Patient Management System, as instructed.
• Work closely with clinical team to advise to any Hold status due to delay in Proton Therapy Authorization.
• Work collaboratively with the Billing team to ensure clean claim submission and accurate reimbursement for Proton therapy treatments.
• Work closely with the Proton center’s contracted authorization vendor, escalating denied cases for additional levels of appeal per organizational processes.
• Follow all Proton therapy patients that are actively under treatment to monitor the need of auth changes or extensions.
• Assist with investigation and resolution of any claim rejections, denials, or appeals related to issues with Proton therapy prior authorizations.
• Stay current with industry trends, changes to insurance policies, and other developments that may impact the pre-service authorization and appeal process in relation to Proton therapy treatments.
• Follows Tennessee Oncology Policy & Procedure parameters as outlined by management to ensure standardization of function.
• Additional responsibilities as assigned to help drive our mission of improving the lives of everyone living with cancer.

KNOWLEDGE, SKILLS & ABILITIES:

• Excellent verbal and written communication skills.
• Working knowledge of government and managed care benefit structures.
• Ability to work collaboratively with a diverse group of individuals, including physicians, patients, insurance providers, and contracted authorization vendors.
• Understanding the day-to-day logistics of a specialty physician practice.
• Strong understanding of medical terminology.
• In-depth knowledge of Radiation Oncology and Proton therapy procedures, required.
• Ability to recognize, evaluate, and solve problems.
• Strong organizational and time management skills.
• Ability to work independently and manage multiple priorities in a fast-paced environment.
• Proficiency with medical billing software.
• Knowledge of Windows-based software applications. (E.g.: Word, Excel, Outlook…)

EDUCATION & EXPERIENCE:

• High school diploma or equivalent required.
• Bachelor’s degree preferred.
• Minimum of 3 years of experience working with insurance pre-authorization and appeal processes, preferably in an Oncology healthcare setting.
• Radiation Oncology/Proton experience required.

LI-REMOTE