Scope of Position

Use of clinical knowledge for the management of complex James Cancer Center ambulatory medical necessity denials through the appeals process. Providing scientific evidence to support cutting edge therapies, and diagnostic services. Providing clinical education to payers regarding current standard of care treatment and other frequently denied services as applicable. Identifying trends, and areas for needed clinical education, to decrease denials where applicable. Submission of pre-determination requests proactively supporting clinicians in efforts to identify areas where loss of revenue is at risk to mitigate that risk. Provide support to the CBO Medicare billing area in the form of correcting billing errors before the bill is sent to the payer. Provide clinical support for the review of clinical data to access current policies and processes impacting revenue. Provide coverage support to the pre-certification area when clinical intervention is required.

Position Summary

Goals and objectives include: Continue to foster effective working relationships with Nurse Managers, clinical staff, and CBO departments providing education and clinical support as appropriate. Pursue hospital reimbursement related to patient services, and other special projects that will decrease loss of revenue, and support the Mission of the James. Facilitates education as needed to ensure compliance, and support strong business practices for the clinical areas.

Minimum Qualifications

Associate Degree in Nursing preferred. Minimum of 3 years oncology experience preferred. Experience with Windows, Excel, Access, and Intranet/internet navigation tools. Minimum of 3 years experience in the field of oncology with solid clinical skills and current clinical practices required. Experience in physician practice, and/or utilization review a plus. Knowledge of Medicare and commercial insurance reimbursement preferred. 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. Use of computer based billing systems, and databases a plus.

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