Care Management Payor Specialist

Position Objective

Facilitates the exchange of clinical information and authorization between the hospital and the third party payors, providing direct support to the utilization review process.

Essential Job Duties

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

• 1.
• Reviews each Case Managers daily work list to identify the clinical reviews due to the payor that day.
• Reports trends in Case Managers failing to provide timely reviews to Care Management leadership.
• 2.
• Communicates medical record clinical information telephonically, written via fax, or electronically to payors to obtain authorization for admission, continued stay or levels of care, and documents in medical record.
• 3.
• Verifies the payor responds to the clinical update provided.
• Contacts payor if a response is not received.
• Initiates appropriate action when a discrepancy in admission status, authorization number or need of clarification is identified.
• Communicate with Case Manager, Care Management leadership, Physicians or Physician Advisors when there are concerns requiring their assistance.
• 4.
• Assures the Case Manager is kept informed of determinations and is notified promptly if additional information is requested or notification of potential denial/denial is received.
• 5.
• Obtains insurance authorization and submits timely clinical information and feedback to the Payors and Care Management nurses; Completes Medical Assistance 3808s

Educational/Experience Requirements

• High school diploma or equivalent.
• One year work experience to include billing/collection experience and/or experience with Medicare, Blue Cross and Medicaid.

RequiredLicense/Certifications

• N/A

Working Conditions, Equipment, Physical Demands

There is a reasonable expectation that employees in this position will not be exposed to blood-borne pathogens.

Physical Demands -

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.