Medical Necessity Specialist

About City of Hope

City of Hope, an innovative biomedical research, treatment and educational institution with over 4000 employees, is dedicated to the prevention and cure of cancer and other life-threatening diseases and guided by a compassionate, patient-centered philosophy.

Founded in 1913 and headquartered in Duarte, California, City of Hope is a remarkable non-profit institution, where compassion and advanced care go hand-in-hand with excellence in clinical and scientific research. City of Hope is a National Cancer Institute designated Comprehensive Cancer Center and a founding member of the National Comprehensive Cancer Network, an alliance of the nation's 20 leading cancer centers that develops and institutes standards of care for cancer treatment.

Job Title: Medical Necessity Specialist

Requisition ID: 14612

Location: Duarte, CA

Position Summary:

Under the supervision of the Laboratory Outreach Manager and Laboratory Leadership, the Specialist oversees and reviews all guarantor/patient billing. The Specialist provides education to department as it pertains to medical appropriateness when ordering tests and services, to ensure compliance with Medicare diagnoses guidelines. Responsible for creating statements, monitor payments, follow up on unpaid claims utilizing monthly aging accounts receivable reports to follow up on unpaid claims aged over 30 days. Filing appeals when appropriate to obtain maximum reimbursement, collects delinquent accounts by establishing payment arrangements with clients and patients;

The Specialist supports both clinical and business process improvement; assists with analysis and interpretation of Medicare LCD/NCD (local coverage determination/national coverage determination) requirements and is proactive in addressing clinical policies that may adversely impact City of Hope. Working in Lab Outreach department and coordinates input and monitors the outcome and notifies manager and appropriate departments when Final LCD/NCD's are published; ensures downstream communication.

The Specialist works closely with Health Information Management (HIM) regarding diagnoses documentation, and provides clarification to resolve potential coding issues. The Specialist also works closely with patient financial services to assure that the required documentation is available to assure payment or reimbursement for services that are provided.

Key Responsibilities include:

  • 5% - Communicates directly with Laboratory Outreach clients and clinicians via clinical documentation query form regarding missing, unclear or conflicting medical record documentation to clarify and obtain needed documentation.
  • 15% - Responsible for the pre-verification of insurance for test orders submitted into the Outreach Department. Ensures insurance coverage by telephone, resolves any issues with coverage and escalates complicated issues to a supervisor or manager.
  • 5% - Regularly tracks and monitors denial activity, authorizations and verification Reports findings to manager and provides recommendations for improvement.
  • 5% - Monitors payments and follow up on unpaid claims utilizing monthly aging accounts receivable reports to follow up on unpaid claims.
  • 5% - Coordinates ABN process and provides compliance support to Laboratory Outreach, HIM, and other ancillary departments as it relates to screening of services for medical necessity.
  • 5% - Data entry of all patient demographic, guarantor and insurance information, posting procedures and insurance/patient payments, balance to daily deposits.
  • 5% - Serves as a clinical resource to patients and clients when an ABN is required or questions concerning the interpretation of policies and their application to individual circumstances.
  • 5% - Monitors and evaluates effectiveness or query outcomes.
  • 5% - Contributes to ABN-related policies and procedures, including ongoing monitoring of compliance to policies.
  • 5% - Research and resolve client billing problems or issues.
  • 5% - Collaborates with Revenue Cycle Compliance analyst to stay abreast of latest NCD and OIG information regarding medical necessity.
  • 5% - Network with other comprehensive cancer centers to stay current on changes in LCD/NCD coverage, and billing/coding practices used nationwide. Provides input on behalf of pharmacy department regarding off-label drug use and coverage/reimbursement issues.
  • 5% - Regularly meet with manager to discuss and resolve reimbursement issues or billing obstacles.
  • 5% - Establishes positive rapport and effective communication with all internal and external customers.
  • 5% - Ensure all claims are submitted with a goal of zero errors.Verifies completeness and accuracy of all claims prior to submission.
  • 5% - Conducts reviews, analysis and provides recommendations to clinical departments.
  • 5% - Assist with drafting, finalizing, updating/revising Policies and Procedures, as they relate to compliance with laws, Medicare Coverage Analysis, National Coverage Decision, statutes and regulations dealing with clinical trial billing issues.
  • 5% - Provides back up support for any cross coverage required, overflow, as defined by Manager, Laboratory Outreach.

Minimum Education: Associate Degree or equivalent in Healthcare or related field.

Minimum Experience:
  • 1-3 years of experience in healthcare coding.
  • Experience in clinical setting, and regulatory compliance preferred.
  • Working knowledge of Medicare Local Coverage Decisions (LCD's) and National Coverage Decisions (NCD's), and medical necessity guidelines for all disciplines (primary: lab and surgery services, pharmacy, radiology,).
  • Experience with payer coverage and reimbursement issues.

Req. Certification/Licensure: CPC (Certified Professional Coder) or equivalent certification.

City of Hope is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, sexual orientation, gender identity, age, status as a protected veteran, or status as a qualified individual with disability.


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