The Oncology Nurse conducts prospective and retrospective review of Chemotherapy, Injectables and Radiation Therapy service requests. Assists with complex cases and internal process development. Interacts with the Oncology Coordinator(s) to direct appropriate utilization and data capture.
ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES:
Determines compliance of Chemotherapy, Injectables and Radiation Therapy across the continuum of care through the application of clinical criteria and Healthcare Management Guidelines.
Identifies cases requiring potential or actual use of medically inappropriate interventions and refers to Medical Director and Pharmacist for review.
Keeps abreast of advances in Chemotherapy, Injectables and Radiation Therapy treatments
Interacts with providers for medical information necessary to adjudicate authorization.
Reviews each authorization if clinical history supports service/procedure requested.
Reviews each authorization for appropriate requested provider for service area.
Reviews home care infusion requests from discharge planning
Reviews and forwards potential denials of service with related clinical information to Medical Director.
Communicates with HCP Medical Directors as to the appropriate treatment plans/interventions for patients diagnosed with Cancer.
Identifies high-risk patients and refers to priority care team for appropriate case management.
Identifies palliative and end stage patients and refers to Hospice and Palliative Program
Investigates and follows up on all additional requests for information by UM Manager or Medical Director.
Interacts with HCP Pharmacists to assess member’s medication changes without affecting continuity of care
Primary interface with the physician on urgent/emergent authorization requests.
Clinical resource for Oncology Coordinators.
Responds to health plan inquiries and requests, and report and submit all pertinent
data in a timely manner.
Performs other functions as necessary to accommodate departmental change, workload and emergencies.
Ensures the privacy and security of PHI (Protected Health Information) as outlined in HealthCare Partners Policies and Procedures relating to HIPAA compliance.
Understanding of all Medical Management Policy and Procedures, and NCQA guidelines.
Participates in special projects as requested by the Clinical Services management team
Participates in weekly priority care rounds
Performs other duties as directed by management.
Skills, Knowledge, Abilities:
Graduate from an accredited Nursing Program.
Current NYS LPN or RN license required.
Five years related experience in an HMO/IPA or medical group.
Three to Five years medical/surgical experience preferred.
Excellent verbal and written communication and organizational skills.
Ability to work independently, self-directed.
Proven ability to manage multiple assignments simultaneously.
Knowledge of ICD-10/CPT codes.
Experience using Milliman Criteria
Previous experience in a Managed Care company preferred.
Typing 40 words per minutes with accuracy.
Knowledge of computers, faxes, printers and all other office equipment.
Knowledgeable in MS Office Programs (i.e., Word, Excel, Outlook, Access and PowerPoint).
Ability to work collaboratively as part of a team.
HealthCare Partners, IPA (HCPIPA) manages and administers healthcare products for contracted health plans. A physician-owned organization, HCPIPA understands the challenges of practicing in a managed care environment and presents its constituents with concrete business solutions. In addition to ensuring that members receive all of the benefits of their health plan, HCPIPA assists its participating... physicians with optimal management of their practices. Through HealthCare Partners, Management Services Organization, providers are offered a streamlined approach to utilization of specialty services. Our contracted network of select referral physicians provides medical services for the majority of our health plan members. HCPIPA physicians enjoy the benefits of membership in a large medical network including:• access to medical experts.• opportunities for far reaching collegial networking.• continuing medical education