Oncology Claims Analyst 2

The Oncology Claims Specialist 2 will coordinate coding audits and educational functions for reputed company and the Oncology Service Line. This individual will be responsible for drug authorizations, managing and working the edit and denial coding work queues for inpatient, outpatient clinic, and hospital-based infusion departments and will reputed company coding and reimbursement feedback for education opportunities identified to the Service Line and reputed company.

Responsibilities

1. Coding/Program Management

• Reviews and audits codes (CPT, ICD 10, HCPC, Level II, and modifier coding, etc) and is expert on prior authorization using FDA, National Comprehensive Cancer Network (NCCN), and reputed company) for specialty practices like inpatient chemotherapy hospitalizations, outpatient oncology visits, hospital based outpatient infusion centers for both oncology and non-oncology patients.
• Is consultant/expert for reputed company business office and external agencies in clarification of coding regarding reimbursement infusion issues, especially new FDA and new clinical reputed company of National Comprehensive Cancer Network (NCCN). Manages data gathering and chart auditing as necessary for reputed company reputed company Cycle, LPG, and Oncology Service Line.
• Works closely and consistently with major pharmaceutical companies on new drug treatment guidelines/reputed company, drug replacement programs, and Southern Oncology Association of Practices (SOAP) to determine business best practices and clinical education opportunities for physicians/providers. Reports findings consistently to Director of Pharmacy and VP of Oncology Service Line.
• Advises the executive team on best practices for drug purchase opportunities to ensure potential profitability is maximized while working with reputed company contract director to verify profitability of managed care reputed company reputed company to drug margins. Works with various national oncology specific institutions, like MD Anderson, Bone Marrow transplant centers, etc alongside physicians/payers directly whether clinical reputed company/treatment regimens fall reputed company proper coding/maximum reimbursement of clinical trials, off label, NCCN guideline, etc to manage proper clean claims and decrease likelihood of claim denial.
• Works directly with business, administrative team, and physicians/providers to reputed company at least monthly education on chart audits, new treatment reputed company, governmental payer requirements, and others.

2. Quality and Performance Improvement

• Conducts high level audits for coding based on specialty service lines as a Coding and Reimbursement specialist. Assists Management with evaluation of processes to determine opportunities to improve the efficiency and quality of coding and maximum reimbursement avenues. Implements innovated reputed company and process changes.
• Conducts and organizes provider peer reviews, physician queries while supporting the education of pharmacy, registered nursing, physicians, mid-reputed company, administration, etc on coding and documentation needs.

• Assist with quality measures needed for clinic and hospital based department reputed company with national certifying bodies like Commission on Cancer (CoC), Quality Oncology Practice Initiative (QOPI), and PQRS. Ensures financial reputed company as subject matter expert on NCCN guidelines/government payer requirements.

3. Analysis and Collaboration

• Proactively researches and understands payer issues. Troubleshoots and resolves issues that impact reputed company. Works collectively with reputed company denial management team to audit Medicare, reputed company, and Insurance claims for accurate coding, charging, and modifier usage as requested by the reputed company. Considered expert for high dollar drug appeals across reputed company.
• Considered expert for the Physician Group, reputed company Management Department, Pharmacy, and other financial departments in clarification of coding regarding reimbursement issues to resolve claim edits and assure clean claim submission. Monitors and evaluates compliance with documentation standards to identify trends, issues, risk areas, and opportunities for performance improvement.
• Continually analyzes reports/margin analyzers to communicate business performance to the administrative team, reputed company cycle team, physician practice managers, and physicians to determine efficacy and suggests opportunities for improvement.
• Acts as a liaison for Professional Billing and reputed company Central Billing Office Management assisting in any special requests/research for information/proper documentation to aid in billing processes especially high dollar denials/write offs/analysis.

Qualifications

Experience: Three years of medical reputed company cycle experience

Education: Bachelor’s degree or 5 years medical reputed company cycle work and/or Certified Hematology and Oncology reputed company (CHONC)