Payor Resource Coordinator

Eisenhower Medical Center; United States; On-site; USD 30,000 - 46,000; Full time

Job summary

Eisenhower Health Careers in the United States seeks a dedicated Case Management/Denials Specialist to help secure payer reimbursements. You will collaborate with the Case Management team, appeal denials, and ensure timely authorization and proper documentation in EPIC.

Qualified candidates have a billing background focused on Managed Care and denials processing, with strong analytical skills and proficiency in Excel and EPIC. This role reports to the Director of Case Management.

Qualifications

• High School diploma or equivalent required; associate degree preferred.
• Two years billing background with emphasis in Managed Care denial follows up and appeals processing.
• Prior hospital billing experience is a plus; patient accounting background in high-volume settings preferred.

Responsibilities

• Demonstrates compliance with Code of Conduct and compliance policies.
• Reviews patient accounts to ensure clinical reviews are submitted to payer.
• Follows up with payer regarding authorized days and documents in EPIC.
• Checks voicemails and faxes for payer requests and routes to appropriate staff.
• Responds to insurance company requests and communicates authorization status.
• Sends IEHP list of patients needing clinical and/or Discharge Summary.
• Obtains insurer approvals and updates systems accordingly.
• Receives payer information via email and routes to the Case Managers.
• Submits denials to the Clinical Appeal Nurse and notifies CM Manager if needed.
• Reviews Outlier report weekly and updates payer information.
• Assists Clinical Appeal Nurse with processing appeals.

Education

High School diploma or equivalent

Associate degree

Tools

EPIC

Windows

Excel

Job description

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 in billing background with an emphasis in Managed Care denial follows up and appeals processing Prior hospital billing experience a plus Preferred: Patient accounting background in a high volume environment experience

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

• Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.


• Reviews all patient accounts to ensure clinical reviews are submitted to payer.


• Follows up with payer regarding authorized days.


• Documents authorized days in EPIC.


• Check voicemails in the morning as well as throughout the day for any payer requests.


• Check the faxes, sort by approvals, denials and other payer requests.


• Regularly answering calls from Insurance companies that are requesting information or giving authorizations.


• 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.


• Sends IEHP a list of patients requesting clinical and/or Discharge Summary.


• Gathers insurance approvals, update in the system and forward to the business office.


• 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.


• Submits denials to the Clinical Appeal Nurse, if patient is still in house copy the floor Case Manager as well.


• Review Outlier report weekly and update payer information.


• Provides assistance to Clinical Appeal Nurse to process appeals.


• Keeps leadership abreast of any Payer issues pertaining to authorization and or denials.


• Other duties as assigned.

Welcome to Eisenhower Health Careers! Eisenhower has been a leader in health care for the Coachella Valley since we opened our medical center in 1971. Since then, we’ve been growing steadily, adding services, capabilities and facilities to anticipate and meet the needs of our expanding area. Today, the Eisenhower name extends far beyond the state-of-the-art care we deliver at the hospital.