Care Management Payor Specialist

Luminis-Health; Annapolis (MD); On-site; USD 27,000 - 40,000; Full time

Job summary

Luminis Health seeks a dedicated professional to facilitate the exchange of clinical information and authorization between the hospital and third party payors, supporting the utilization review process.

Responsibilities include coordinating payor authorizations for admissions and levels of care, and ensuring timely communication with Case Management and care teams. Requires a high school diploma and at least one year of billing/Medicare/Medicaid experience.

Qualifications

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

Responsibilities

• Reviews each Case Managers daily work list to identify clinical reviews due to the payor that day; reports trends in missed timely reviews to Care Management leadership.
• Communicates medical record clinical information telephonically, via fax, or electronically to payors to obtain authorization for admission, continued stay or levels of care, and documents in the medical record.
• Verifies payor response; contacts payor if no response and initiates action; communicates with Case Manager, Care Management leadership, Physicians or Physician Advisors when concerns arise.
• Keeps Case Manager informed of determinations and notifies promptly if additional information is requested or denial is anticipated.
• Obtains insurance authorization and submits timely clinical information and feedback to Payors and Care Management nurses; completes Medical Assistance 3808s.

Skills

Billing & Collections

Medicare/Medicaid knowledge

Education

High school diploma or equivalent

Job description

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.

Required License/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.

The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.

Pay Range

$19.30 — $28.94 USD

Luminis Health Benefits Overview:

• Medical, Dental, and Vision Insurance
• Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year)
• Paid Time Off
• Tuition Assistance Benefits
• Employee Referral Bonus Program
• Paid Holidays, Disability, and Life/AD&D for full-time employees
• Wellness Programs
• Employee Assistance Programs and more
• Benefit offerings based on employment status