CARRIE CYRUS

Sr. Infusion Insurance Liaison

Methodist Sugarland Hospital

Sugarland, Texas

05.2008 - Current

Assist in Training new hire for preauthorization for Oncology/Hematology/Rheumatology
Verifies insurance coverage for patient admissions; makes written and/or verbal inquiries to third party payers to verify insurance status and pre-certification status and to follow-up payment denials.
Performs various clerical tasks to expedite the verification process, including documentation of guarantor information, patient information and protocols, and medical record reproduction.
Obtain pre- certs or predetermination for Chemo patients.
May assist the Physician/Pharmacist or clinical staff in office in clinic setting up a peer to peer.
Schedule and clear patients for services.
Assist in coordinating the efficient flow of information between patients, the medical staff and third-party requestors.
Serves as a consultative and/or advisory role to team members of Revenue Cycle regarding clinical appeals and clinical logic determination.
Reviews inpatient accounts to confirm an authorization is present if one is required. If an authorization is not present, escalation occurs to obtain and populate the authorization prior to billing.
Review outpatient operative reports and procedure notes to validate consistency of CPT/HCPCS codes submitted for procedure billing authorization.
Reviews patient clinical history to determine if the recommended status following the procedure is appropriate and notify the provider if not.
Identifies gaps in clinical documentation and works with clinical staff to develop and implement quality improvement and staff education initiatives.
Consults with ordering physicians when insurance authorization or coverage is in question prior to scheduled services to determine if the visit will be rescheduled, canceled, or proceed.
Uses benefits and order information on file to initiate and secure preauthorizations in advance of the day of care.
Documents all payer communications thoroughly and communicated payer decisions in a timely manner.
Evaluates individual patient's needs, medical and hospital policies, cost of treatment, and insurance guidelines to determine if the scheduled course of treatment is medically necessary.
Provides support with medical necessity appeals once denial is received.
Performs all other duties as assigned.
Assisting in the interview process for new candidates.
Reviews, processes, and audits the medical necessity for each patient chemotherapy treatment and documentation of regimen relative to pathway adherence.
Communicates with nursing and medical staff to inform them of any restrictions or special requirements in accordance with insurance plans.
Provides prompt feedback to physicians and management regarding pathway documentation issues, and payer issues with non-covered chemotherapy drugs.
Updates coding/payer guidelines for clinical staff.
Tracks pathways and performs various other business office functions on an as needed basis.
Research additional or alternative resources for non-covered chemotherapy services to prevent payment denials.
Provides a contact list for patient's community resources including special programs, drugs and pharmaceutical supplies and financial resources.
Maintains a good working knowledge of chemotherapy authorization requirements for all payers, State and federal regulatory guidelines for coverage and authorization.
Adheres to confidentiality, state, federal, and HIPPA laws and guidelines with regards to patients 'records.
Provided ongoing support and mentorship to staff, addressing EPIC-related questions and challenges in a timely manner.
Managed the certification process for EPIC users, ensuring all staff met required proficiency levels before granting system access.
Utilized EPIC's reporting functions to track employee progress and certification status, ensuring compliance with hospital policies and external regulations.
Conducted workflow analysis, space design or cost comparison analysis.
Performed variety of clerical and administrative duties pertaining to on-site support.

Summary

Overview

Work History

Sr. Infusion Insurance Liaison

Care Reviewer Processor

Education

Sociology/Psychology -

Certified Medical Assistant -

Skills

References

Timeline

Care Reviewer Processor

Sr. Infusion Insurance Liaison

Sociology/Psychology -

Certified Medical Assistant -

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