Clinical Financial Case Mgr

Scope of Position

Finance establishes financial controls and policies, ensures controls are implemented and effective, executes financial operations, prepares and interprets financial and operational reports, and supports strategic decisions.

Position Summary
This position uses clinical knowledge for the management of the complex process of coordinating insurance verification and prior authorization of outpatient medications; provides evidence to support cutting edge therapies; provides clinical education to payers regarding current standard of care treatment. Identifies trends, and areas for needed clinical education, to decrease denials where applicable. Submission of test claims proactively supporting clinicians in efforts to identify areas where risk of denial is high to mitigate that risk. Responsibilities also include understanding and verifying benefits and obtaining prior authorization for outpatient medications. In addition, the position will at times contact patients/families in order to ascertain additional demographic, financial, and insurance information essential to the authorization processes while also informing patients of medication co-pays. Having strong clinical knowledge, utilizes the electronic medical record system to obtain pertinent medical information for prior authorization process. Solves complex customer problems. Evaluates and solves complex issues/problems; communicates and consults with the clinical team.

Minimum Qualifications
Bachelor Degree in Nursing, Pharmaceutical Sciences or similar clinical healthcare field required. At least 1 year of clinical experience required preferably in the field of oncology and/or pharmacy. Experience in physician practice and/or utilization review a plus. Knowledge of Medicare and commercial insurance reimbursement desired. Strong knowledge of medical and pharmaceutical terminology highly desired. Strong knowledge of ICD-9-CM, HCPCs, and CPT coding preferred. Excellent verbal and written skills required. Proficient in the use of computer based research and medical record documentation required. Experience in interpreting insurance benefit information and completing prior authorization process preferred.