Job Description

The Oncology Claims Analyst 1 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. Prepares and presents coding education to providers and works in collaboration with various hospital and FMOLHS departments as a liaison related to NCCN, ASCO, and FDA guidelines. Must be familiar with reviewing documentation to assign appropriate CPT/HCPCS and ICD-10-CM-PCS diagnosis codes, understand current professional coder workflows, reviews principal, secondary diagnoses and procedures for hospital and physician (professional) services for inpatient, outpatient, and infusion records based on knowledge of coding systems. Additionally serves as business/reimbursement specialist for oncology drug regimens for both 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. 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.
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: 3 years of medical revenue cycle experience
• Education: High School Diploma