Oncology Claims Analyst 2

The Oncology Claims Specialist 2 will coordinate coding audits and educational functions for FMOLHS 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 provide coding and reimbursement feedback for education opportunities identified to the Service Line and FMOLHS. 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 American Society of Clinical Oncology (ASCO) 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 FMOLHS business office and external agencies in clarification of coding regarding reimbursement infusion issues, especially new FDA and new clinical pathways of National Comprehensive Cancer Network (NCCN). Manages data gathering and chart auditing as necessary for FMOLHS Revenue Cycle, LPG, and Oncology Service Line. Works closely and consistently with major pharmaceutical companies on new drug treatment guidelines/pathways, 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 FMOLHS contract director to verify profitability of managed care contracts related to drug margins. Works with various national oncology specific institutions, like MD Anderson, Bone Marrow transplant centers, etc alongside physicians/payers directly whether clinical pathways/treatment regimens fall within 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 perform at least monthly education on chart audits, new treatment pathways, 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 ideas and process changes. Conducts and organizes provider peer reviews, physician queries while supporting the education of pharmacy, registered nursing, physicians, mid-levels, administration, etc on coding and documentation needs. Assist with quality measures needed for clinic and hospital based department success with national certifying bodies like Commission on Cancer (CoC), Quality Oncology Practice Initiative (QOPI), and PQRS. Ensures financial success 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 revenue. Works collectively with FMOLHS denial management team to audit Medicare, Medicaid, and Insurance claims for accurate coding, charging, and modifier usage as requested by the FMOLHS. Considered expert for high dollar drug appeals across FMOLHS. Considered expert for the Physician Group, Revenue 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, revenue cycle team, physician practice managers, and physicians to determine efficacy and suggests opportunities for improvement. Acts as a liaison for Professional Billing and FMOLHS 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. Experience: Three years of medical revenue cycle experience Education: Bachelor’s degree or 5 years medical revenue cycle work and Certified Hematology and Oncology Coder (CHONC)