At Bristol Health, we begin each day caring today for your tomorrow. We have been an integral part of our community for the past 100 years. We are dedicated to providing the best possible care and service to our patients, residents and families. We are committed to provide compassionate, quality care at all times and to uphold our values of Communication, Accountability, Respect and Empathy (C.A.R.E.). We are Magnet ® and received the 2020 Press Ganey Leading Innovator award for our rapid adoption and implementation of healthcare solutions during the COVID-19 pandemic. Use your expertise, compassion, and kindness to transform the patient experience. Make a difference. Make Bristol Health your choice.

Responsible for coordinating and supporting initiatives relative to the evaluation, processing, and handling of insurance claims for inpatient and observation Medical / Surgical admissions. Acts as a liaison between the organization, its insurance provider, and clinical staff regarding the status and eligibility for coverage for all relevant admissions. Combines business and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided. Coordinates communication with physicians, case managers, revenue cycle personnel and payers in the appeal of denials.

Essential Job Functions and Responsibilities:

• Validates admission order matches level of care order in billing system to make sure that billing requirements are met. Notifies the case manager when discrepancies are identified and monitors for resolution.
• Forwards clinical summary and other relevant data to payer to secure authorization for the ordered level of care. Monitors payer response for timely determination.
• Commutates with payer as needed after 24hours to verify authorization and status.
• Contacts case manager to gather additional data as needed to support the ordered level of care and forwards to payer.
• Engages the case manager in communication with the payer as needed to prevent denial.
• Communicates concurrent denials to attending physician and case manager for immediate peer to peer review.
• Records authorization numbers in computerized UR module in preparation for billing.
• Contacts the physician advisor to review retrospective denials and determine appeal status.
• Coordinates the submission of appeals to third party payers within allotted timeframes to prevent fiscal penalties.
• Maintains dialogue with payers about disputed claims and maintains documentation of ongoing efforts for each disputed claim.
• Interfaces with Physicians, Patient Financial Services, Patient Access and Medical Records to obtain necessary information as needed to assist with respond to denials.
• Enters all denial activity into computer denial software for tracking of denial activity on a daily basis as third party payer responses are received.
• Utilizes Physician Advisor to interface with Physicians as needed.
• Jointly maintains with Finance:
• Tracking of denials;
• The level in the appeals process for each denial;
• The financial impact of denial management outcomes;
• And successfully overturned decisions.

Educational / Minimum Requirements:

The minimum of a high school diploma is required. A minimum of 2 years experience working in a hospital admissions/billing setting or discharge planning and familiarity with insurance authorization processes. Competitive applicants have a working knowledge of medical terminology and are familiar with insurance and hospital billing policies and procedures.

State/Federal Mandated Licensure or Certification Requirements:

None

Bristol Hospital Mandated Educational Requirements:

General orientation at time of hire. Fire/Safety/Infection Control annually. Other programs as mandated by Hospital.

Special Requirements:

Comfortable dealing with large amounts of data quickly and efficiently. Experience working with insurance companies, and have extensive knowledge of different types of coverage and policies. Excellent multitasking skills, with the ability to work on many projects at once. Must be detail oriented and organized, to maintain accurate patient insurance records. Must work well with others, as part of a health care team, striving to provide patients with the best care possible.

Basic knowledge of computers and clinical/billing applications. Able to work with limited supervisor and prioritize work. Escalates cases that deviate from the normal process to manager in a timely manner.

Physical Requirements:

Work Environment:

Normal office conditions.

Cognitive Requirements:

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities from time to time, as needed.