What You Will Do:

Performs timely and accurate utilization review for all patient populations, using nationally recognized care guidelines/criteria relevant to the payer.

Communicates with case manager, physician advisor, medical team and payors as needed regarding reviews and pended/denied days and interventions.

Supports concurrent appeals process through proactive identification of pended/denied days. Implements the concurrent appeals process with appropriate referrals and documentation.

Ownership of Regulatory Compliance related to Utilization Management conditions of participation

Assures appropriate reimbursement and stewardship of organizational and patient resources.

Actively reports opportunities to improve reimbursement and responds to relevant data

Collaborates with admitting specialists regarding authorization policies and procedures of third party payers.

Remains current on clinical practice and protocols impacting clinical reimbursement

Responsible for defined accounts receivable. Accountable for reduction of Accounts Receivable equal to goals set by senior management.

Works with third party insurance and payer contracting department to obtain maximum level of cash to reduce receivable. Follows up with insurers to recover inaccurate payments.

Reviews accounts to ensure accuracy of billing/charging utilizing knowledge of pre-certification /prior authorization procedures to validate account status. Resolves any problems with billing or handling of accounts. Submits updates and enters authorization for visits and mediation.

Handles patient concerns with professionalism and excellent customer service skills. Relays any patient suggestions and complaints to immediate supervisor for consideration. Provides answers for patient’s questions in a reasonable response time.

Follows departmental guidelines for handling delinquent accounts receivable.

• Utilizes compassionate care program appropriately.
• Researches all avenues of funding for patients who exhibit financial need.
• Works with the Medical Assistance Eligibility team to refer patients through the Medical Assistance process and register patients with ASO.

Gathers and records data for the purpose of enhancing and perfecting collection procedures. A. Shares information with the team to improve the integrity of data. B. Shares information with administrator to solve existing problems with systems or data and effectively promotes avoidance of future problems.

Effectively updates and/or views data in all accessible systems.

Assists supervisor with hiring selection and new staff training.

Accommodates all visitors with accurate information and professionalism.

Performs appeals process when appropriate.

Promotes accuracy among all accounts by thoroughly reviewing all transactions

Maintains a thorough understanding of financial references, including guidelines for reimbursement, state and federal regulations, payor-specific reimbursement policies, procedures and resource material references.

• Notifies supervisor of problem accounts which may lead to significant financial loss.
• Utilizes appropriate letters as necessary to promote communication to patients and insurers on a large scale

Works self-pay Accounts Receivable, updating patient accounts with documentation of follow up activity, new demographic or insurance information on the patient account and in the production log within Resolute. Liaison with outside collection vendors. Handles incoming and outgoing patient correspondences, as directed.

Performs other related duties as required or assigned.

What You Need to Be Successful:

Education

Required: High School Diploma or GED.

Experience:

3 years Professional Fee billing experience required.

Knowledge of utilization management is preferred.

Highly effective verbal and written skills are required.

Strong communication skills, self-confidence and experience in working with physicians are required.

Excellent analytical and team building skills, as well as the ability to prioritize and work independently are required.

The ability to work collaboratively with other disciplines is required.

Ability to work with Hospital/ Utilization Management and related software programs is required.

We are an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law.