Payor Resource Coordinator

Default Work Shift:

Day (United States of America)

Hours:

40

Salary range:

$21.75 - $33.04

Schedule:

Full Time

Shift Hours:

8 Hour employee

Department:

Case Management Social Services

Job Objective:

Works to secure reimbursement for care provided by working closely with Payer, ensuring authorization, notification, and clinical reviews are completed and faxed in a timely manner by the Case Management staff. Works closely with Clinical Appeal Nurse and department leadership to ensure all denial are appealed and provides follow up with payer on appeal status. Communicates clinical denial and status of appeal to appropriate departments and/or personnel for follow up and documents in EPIC accurately and consistently.

Job Description:

Education:
Required: High School diploma or equivalent
Preferred: Associate degree

Licensure/Certification:
N/A

Experience:
Required: Two (2) years of healthcare experience involving insurance authorization coordination, communication with managed care plans, utilization management support, or related care coordination activities.

Preferred: Experience working with managed care plans in a high-volume healthcare environment, such as an acute care hospital or health plan. Familiarity with initial and concurrent authorizations and insurance authorization processes preferred.

Reports To: Director, Case Management Supervises: N/A Ages of Patients: N/A Blood Borne Pathogens: Minimal/ No Potential

Skills, Knowledge, Abilities:

Ability to prioritize and coordinate workflow and attention to detail, Knowledge of payor specific requirements and reimbursement, Strong Analytical skills, Proficient in Microsoft Windows with emphasis on Excel, Working knowledge of LC D’s, NC C I and MUE edits as well as a general knowledge of C commercial, HMO and Blues claims , authorization and documentation requirements

Essential Responsibilities

1. Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.
2. Reviews all patient accounts to ensure clinical reviews are submitted to payer.
3. Follows up with payer regarding authorized days.
4. Documents authorized days in EPIC.
5. Check voicemails in the morning as well as throughout the day for any payer requests.
6. Check the faxes, sort by approvals, denials and other payer requests.
7. Regularly answering calls from Insurance companies that are requesting information or giving authorizations.
8. Notifies the Case Managers of clinical requests. If the patient is no longer in the hospital, faxes the UR notes, H&P and admit order. If there are no UR notes or patient was here for an extended period of time and there was only and initial, inform the CM Manager.
9. Sends IEHP a list of patients requesting clinical and/or Discharge Summary.
10. Gathers insurance approvals, update in the system and forward to the business office.
11. Receive emails from PFS with information regarding patients insurance and clinical requests. If patient is discharged, faxes information to payer from UR module in EPIC. If patient is in house, forwards the email to the appropriate Case Manager.
12. Submits denials to the Clinical Appeal Nurse, if patient is still in house copy the floor Case Manager as well.
13. Review Outlier report weekly and update payer information.
14. Provides assistance to Clinical Appeal Nurse to process appeals.
15. Keeps leadership abreast of any Payer issues pertaining to authorization and or denials.
16. Other duties as assigned.