Find & Apply For Insurance Claims / Policy Clerk Jobs in Royal Oak, Michigan

Description:

The Oncology Authorization Specialist acts as the vital bridge between clinical intent and financial execution. This is not a generalist role; it requires a deep understanding of oncology treatment pathways, including chemotherapy infusions. You will serve as a clinical-financial advocate, ensuring that every patient receives life-saving treatment without delay by masterfully navigating the complex landscape of payer medical policies and NCCN guidelines. Key Responsibilities & Impact 1.

Strategic Authorization Management Clinical Alignment:

Review of physician orders against NCCN Guidelines and Compendia to ensure medical necessity is clearly demonstrated before submission.

Precision Medicine:

Manage authorizations for infusions, injections, and biomarker-driven therapies, ensuring the correct ICD-10 and CPT pairings are utilized.

Lifecycle Management:

Proactively track authorization lifespans to prevent "gap-in-care" scenarios, managing dosage escalations and regimen changes in real-time. 2.

Financial Advocacy & Payor Navigation Payer Expertise:

Act as the subject matter expert on Medicare Part B vs. Part D coverage, "Buy and Bill" workflows, and site-of-service differentials.

Denial Prevention:

Analyze payer medical policies to identify potential hurdles (e.g., step therapy with biosimilars) before they result in denial.

Appeals Leadership:

Lead the "Letter of Medical Necessity" (LMN) process, partnering with physicians to provide evidence-based arguments for peer-to-peer reviews. 3.

Patient-Centric Coordination Time-to-Treat Optimization:

Minimize the "days to first treatment" by navigating urgent authorization requests with a sense of clinical urgency.

Interdisciplinary Collaboration:

Serve as a core member of the care team, providing updates to Nursing and Financial Counselors regarding clearance status.

Requirements:

3+ years of dedicated Oncology authorization or billing experience. Proficiency in NCCN Guidelines, cancer staging, and the distinction between curative and palliative intent. Advanced knowledge of HCPCS (J-Codes/Q-Codes), CPT administration codes, and Oncology-specific ICD-10 coding. Expertise in EMR systems, insurance portals, and clearinghouses. Preferred Skills for

High-Level Candidates Biosimilar Strategy:

Understanding the financial and clinical shift toward biosimilar utilization and payer-preferred product lists.

Specialty Pharmacy Nuance:

Experience managing the "White Bagging" vs. "Brown Bagging" workflows and their impact on clinic revenue and patient safety.

Resilience:

The ability to remain empathetic yet persistent when navigating the bureaucracy of insurance denials.