Payor Specialist ^60165 - WVU Healthcare (Morgantown, WV)

Title Payor Specialist ^60165 Req Number 12-03449 Open Date 12/26/2012 Description Payor Specialist Summary: Collaborates with Outcomes Managers/Clinical Care Coordinators (OM/CCC) to provide specific clinical information to third party payors; responsible for timely provision/flow of clinical information to/from third party payor and OM/CCC to ensure certification/approval of inpatient and post discharge services. Essential Duties and Responsibilities: • Effectively communicates clinical information and negotiates with payors to obtain authorization for appropriate level of care and length of stay and documents interactions in information system • Provides prompt feedback regarding payor determinations to OM/CCC, enabling them to evaluate/redirect the current patient plan of care in order to streamline the delivery of service • Obtains payor certification and provider information for home care, DME and post acute services • Enters and maintains certification information on appropriate information system • Proactively communicates any change in payor information to OM/CCC and documents changes appropriately • Provide prompt follow up with the Payor to ensure current authorization and accurate payment for the patient’s stay. • Identifies concurrent denials by third party payors and notifies CCC/OM for immediate intervention • Acts as a resource to Care Management staff relative to concurrent denials and retrospective authorization requests as per payor. • Assists with appeals denials based on medical necessity, includes completion of necessary documentation and coordinates with Care Management staff • Provides information for pattern/trends for analysis of denials and appeals to the Care Management team re. (practitioners, diagnosis, patient location, avoidable days) • Attends payor specific meetings as needed. • Collaborates with Financial Services regarding all incoming retrospective denials and the distribution of denials as well as tracking and trending • Ensures payor and customer satisfaction through effective communication and positive customer service skills at all times • Function as placement specialist as required to include research for preferred providers for HHC/DME/Acute Rehab/SNF/LTACH placement. • Maintains, updates, and disseminates payor grid • Participates in performance improvement activities • Acts as a liaison to share patient-specific insurance and updates to pertinent areas • Identifies areas for improvement • Negotiates concurrent denials and communicates findings to finance • Verify with patient financial counseling that all payment sources have been explored, including charity • Maintains confidentiality of communications Performance Standard: Adheres to the established Performance Expectations for WVUH Employees in the areas of People, Service, Performance Improvement, and Shared Values & Culture. Adheres to the Care Management Department Scope of Service policy and Standards of Practice policy Position Requirements Minimum Qualifications · High School Diploma or GED required · Associate or advanced degree preferred. · Two to three years experience in a health care setting preferred. · One year of ICD9/CPT Coding or Medical Terminology knowledge required. · Knowledge of third party reimbursement or utilization management skills preferred. Department CARE MANAGEMENT ^403 WVUH Shift Day/Afternoon WVUH Full-time/Part-time Full-time (40 hours) Internal Transfer Only No About the Organization Looking for a challenge? If you are motivated, talented, and eager, there''s a future for you at WVU Hospitals. We are looking for people with the desire to make a difference in healthcare. WVU Hospitals, a 531-bed tertiary care center, teaching institution, that includes: Ruby Memorial Hospital WVU Children''s Hospital Chestnut Ridge Center (behavioral medicine) Jon Michael Moore Trauma Center Physician Office Center Eye Institute Mary Babb Randolph Cancer Center Betty Puskar Breast Care Center WVU Heart Institute Clark K. Sleeth Family Medicine Center Rosenbaum Family House Cheat Lake Physicians Urgent Care Center for Reproductive Medicine Pain Management Center Wound Management Center Sports Medicine Center Sleep Evaluation Center WVUH-Eastern Division (in the eastern part of the state) Our employees are our most valuable asset. We offer competitive pay and benefits because we want to attract and retain employees who will support our mission of high quality patient care. WVUH Hours per Week 40 Notes to Applicant None Specified WVUH Start/End Time 8a-430p

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