Insurance Reviewer-Clinical

ANNUAL SALARY (DEPENDING ON SKILLS/EXPERIENCE): $47,096.00 - $79,747.00

SCOPE: Responsible for working in assigned referral WQs to obtain required referrals/authorizations for requested patient care. Review orders and interpret what services/CPT/HCPCs are required. Based on payer requirements enter request attaching required medical records. Perform required follow up until receipt of final decision; if not favorable reach out to provider to request next steps. Provide communication between Authorization Department and sites via email, phone and/or in-basket.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Perform timely review of assigned WQs to ascertain next steps; prioritizing requests based on due date, stat, urgent, etc. Monitor and process external order WQs
• Review patient chart for MD orders to determine services/CPTs/HCPCs and reasons for requests.
• Review insurance guidelines. If services requested meet medical necessity, gather data to be prepared for phone call, on-line and/or fax to insurance. If no auth required request a Pre D and return authorization approved. If services do not meet payer guidelines, reach out to RCAUTHSUP and/or ordering provider for next steps. If request is denied by insurance, request for peer to peer and/or submit written appeal.
• Enter authorized services into system and all notes pertaining to phone calls.
• Provide communication for sites/providers via email, phone and/or in-basket.
• Maintain in-box and fax folder; import medical guidelines via E-scan into EPIC.
• Complete any assigned WQ and referral projects.
• Maintain a 90% or greater audit and productivity score.

EDUCATION / TRAINING REQUIREMENTS:

• GED / Diploma - High School required
• 2 Years - Business Admin / Healthcare / Related Field preferred

LICENSES / CERTIFICATIONS / REGISTRATION:

• Certificate Medical Billing or Insurance preferred

EXPERIENCE REQUIREMENTS:

• 6 months Healthcare Insurance in Medical / Hospital environment required.
• 6 months EMR required

BENEFITS & PERKS:

• Medical, Dental, & Vision Insurance for Full & Part Time Employees
• 401k Retirement & Matching Plan
• Generous PTO and Paid Holidays
• Continuing Education
• Reimbursement Program
• And Much More!

It is the policy of Epic Care to afford equal opportunity for employment to all individuals regardless of race, color, religion, sex, sexual orientation, gender identity, age, national origin, family status (including pregnancy), marital status, military status, sensory, physical, or mental disability, genetic information, or any other factor protected by local, state or federal law, and to prohibit harassment or retaliation based on any of these factors.

Epic Care is an Alcohol and Drug-Free workplace. Learn more about Epic Care at

Our mission is safe patient care; we require all our employees to be vaccinated as such vaccinations are available and subject to the narrow exceptions provided by applicable law.

PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is required to be present at the employee site during regularly scheduled business hours and regularly required to sit or stand and talk or hear. Requires full range of body motion including handling and lifting patients, manual and finger dexterity, and eye-hand coordination. Requires standing and walking for extensive periods of time. Occasionally lifts and carries items weighing up to 40 lbs. Requires corrected vision and hearing to normal range.

WORK ENVIRONMENT: The work environment may include exposure to communicable diseases, toxic substances, ionizing radiation, medical preparations and other conditions common to an oncology/hematology clinic environment. Work will involve in-person interaction with co-workers and management and/or clients. Work may require minimal travel by automobile to office sites.