Health Insurance Authorization Coordinator IV Job at University of Rochester (Rochester)

Job Description

Provides accurate financial clearance and patient financial account management related to inpatient and outpatient services. Follows patients through their course of treatment to ensure payment for the service, as well as coverage for the necessary medications and/or post-operative equipment. Responsible for the analysis, validation and regulatory and compliance activities associated with the financial clearance process. Mitigates the financial risk to URMC by performing an accurate financial clearance review along with a comprehensive analysis of patient and payor-specific benefits and patient liability.

Job Responsibility

Provides accurate financial clearance and patient financial account management related to inpatient and outpatient services
Follows patients through their course of treatment to ensure payment for the service, as well as coverage for the necessary medications and/or post-operative equipment
Responsible for the analysis, validation and regulatory and compliance activities associated with the financial clearance process
Mitigates the financial risk to URMC by performing an accurate financial clearance review along with a comprehensive analysis of patient and payor-specific benefits and patient liability
Creates a professional and effective customer-oriented environment by obtaining pertinent demographic information, explaining insurance benefits and limits, informing patients of the anticipated costs of services, patient liability, and patient responsibilities, explaining billing policies, and discussing financial options
Advises and guides patients on switching insurance carriers, when applicable, to ensure the best coverage for both patient and hospital/provider reimbursement
Assists patients and their family with insurance questions and resolution of billing issues
Performs crisis intervention when financial issues arise pre- and post-treatment
Obtains benefits and pre-certification along with all other billing requirements
Maintains updated knowledge of hospital contract for in and out-of-network payers
Identifies non-covered hospital services, inquires how the financial obligation will be met, analyzes patient’s financial status and advises patient on the best course of action for payment
Prepares financial packets based on each individual patient’s benefits, financial interview, and calculated estimated expenses
Communicates with Clinical teams to obtain treatment plans and discharge planning to begin the insurance verification process
Processes clinical information required by third party payers in a timely manner
Updates relevant electronic medical records with financial and insurance information on all potential candidates and transplant recipients
Analyzes, organizes, and utilizes complex data and rules related to contracting and patient benefits to provide financial clearance
Set up visits in electronic medical record for anonymous donors who come to SMH for donation
Creates Transplant and Donor guarantors with accompanied bundled billing episodes
Identifies global/bundled billing episode, terms, period in which it is valid, and notifies appropriate URMC parties
Reviews, analyzes and acts upon discrepancies prior to billing
Refers cases to leadership when additional coverage is necessary
Resolves Medicare coordination of benefits discrepancies, as well as prescription coverage issues with Social Security Administration, for reinstatement of benefits
Oversees a caseload of patients on the wait list and maintains case files in accordance with current state, federal and agency rules
Maintains weekly status of all pending cases and take appropriate action to resolve them
Processes referrals to financially screen potential candidates
Performs monthly re-verification of insurance coverage for waitlisted patients
Responsible for re-approvals when patient approaches approval expiration
Monitors patients to ensure timely application for Medicare, by the end of the 30-month coordination period
Reviews the top 10 liver patients by blood type and updates the liver database with insurance and authorization timeframe
Reviews Medicare for MSP questions and validations
Ensures compliance with the Office of the Inspector General guidelines by notifying patients of exhausting Medicare benefits and the option to utilize lifetime reserve days
Ensures appropriate documentation is on file for assigned caseload
Obtains all required signatures for payment of hospital services
Ensures patients are financially cleared following UNOS requirements and documentation listed in EPIC
Maintains a thorough knowledge of insurance carriers’ policies and benefit levels as it relates to each specialty
Works closely with clinical teams in Solid Organ and BMT/CAR-T
Alerts the clinical team of any issues that may impact patient’s ability to undergo the procedure
Works collaboratively with clinical team on authorization denials and inquires on appeal process with the insurance payer
Attends weekly selection committee meetings
Attends quarterly billing meetings to discuss pharmacy, insurance coverage and/or billing problems
Attends the annual educational Transplant Financial Conference on rotation
Monitors and participates in Transplant Financial Coordinator national email listserv
Trains other staff, as assigned by management

Requirements

High School diploma or equivalent and 3 years of related experience required
Associate's degree preferred
High degree of professionalism and motivation with excellent written and verbal communication and customer service skills required
Ability to work independently, as well as in a team environment required
Flexibility to be on call and work other assigned hours, weekends required
Extensive knowledge and comprehension of ICD-10 and CPT coding, medical terminology, and insurance standards and regulations preferred
Strong computer skills and ability to type 45 words per minute preferred
Position may be subject to membership and certification with the Transplant Financial Coordinators Association upon hire preferred

Nice to have

Extensive knowledge and comprehension of ICD-10 and CPT coding, medical terminology, and insurance standards and regulations
Strong computer skills and ability to type 45 words per minute
Membership and certification with the Transplant Financial Coordinators Association upon hire

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Health Insurance Authorization Coordinator IV

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