This is a remote position under Revenue Cycle Management that is responsible for obtaining all medical necessity approvals for a patient’s service and/or verifying they meet any medical policy criteria required by the patient’s insurance. They evaluate, collect, and submit all necessary information accurately to secure the highest possibility of approval. If an insurance request is rejected/denied, they facilitate denial mitigation steps and effectively communicate what is needed to care teams, operational teams, various other internal customers, and patients/guarantors.

Job Expectations:

• Review medical chart/history and physician order(s) to determine likely ICD and CPT codes and/or utilize available coding resources.
• Screen payer medical policies to determine if the service meets medical necessity guidelines.
• Review and determine appropriate clinical documentation to submit to ensure a complete authorization request. 
• Submit and manage authorization requests and/or ensure that pre-certification and admission and discharge notification requirements are met per payer guidelines.
• Facilitate insurance denial mitigation steps such as peer-to-peer reviews and appeals in conjunction with revenue cycle, care teams, utilization review, and patients/guarantors.
• Maintain knowledge of current payer requirements and general ordering/admitting practices, including use of online payer applications and initial/ongoing training.
• Collaborate with all necessary stakeholders to minimize financial risk and ensure the best possible outcome for each patient.
• Use transparent and thoughtful communication, critical thinking, multi-tasking, time management, and prioritization skills to ensure successful completion of all duties, including presentations and meeting facilitation.
• Adapt to rapid changes in workflow and leader direction, utilize all available resources to problem solve and troubleshoot independently, and capitalize on constructive feedback for enhanced outcomes.
• Complete timely, accurate work and contribute to the process or enablement of collecting expected payment.
• Understand/adhere to Revenue Cycle’s Escalation Policy and work collaboratively to achieve personal, team, and organization metric and behavioral goals.

Organization Expectations, as applicable:

• Demonstrates ability to provide care or service adjusting approaches to reflect developmental level and cultural differences of population served.
• Partners with patient care giver in care/decision making.
• Communicates in a respective manner.
• Ensures a safe, secure environment.
• Individualizes plan of care to meet patient needs.
• Modifies clinical interventions based on population served.
• Provides patient education based on as assessment of learning needs of patient/care giver.
• Fulfills all organizational requirements.
• Completes all required learning relevant to the role.
• Complies with and maintains knowledge of all relevant laws, regulations, policies, procedures and standards.
• Fosters a culture of improvement, efficiency, and innovative thinking.
• Performs other duties as assigned.

Required 

Education 

• Associate degree in business, healthcare, or related area. 2 years of revenue cycle experience may substitute for an associate degree.

Experience 

• 1 year of experience working in revenue cycle, insurance verification, financial securing, or related areas using an EHR or enterprise software system in a healthcare organization. This experience must be in addition to two years of experience in lieu of associate degree requirement above.
• Knowledge of insurance terminology, plan types, structures, and approval types
• Knowledge of computer systems, including Microsoft Office 365

Preferred 

Experience 

• Referrals and/or prior authorization experience
• Epic experience
• Knowledge of medical terminology and clinical documentation review