What are the responsibilities and job description for the PATIENT NAVIGATOR-CLINICAL LEAD - PATIENT ACCESS position at North Oaks Health System and Careers?
Status: Full Time
Shift: 40 hours days varies
Exempt: No
Summary:
The Patient Navigator Clinical Lead (PNCL) is responsible for facilitating timely and complete access to care including, but not limited to coordination and completion of appointments/healthcare services, payer authorization and financial clearance of patients seeking medical services. The PNCL works with the patient and the clinical teams to remove barriers to access and improve the patient experience by navigating the health care system and providing the patient with communication for their health care needs. The PNCL serves as a team lead providing immediate oversight, education and support to Patient Access and other healthcare team members.
Other information:
A. Experience, Knowledge and Skill
1. Previous Experience:
- At least 2 years of experience working in a healthcare setting is required
- Experience with insurance authorization is preferred
2. Specialized or Technical Education:
- LPN licensing required or
3. Manual or Physical Skill Required:
Must possess good physical health.
4. Physical Effort Required:
Strength: Medium Push: Occasionally Pull: Occasionally
Carry: Occasionally Lift: Occasionally Sit: Frequently
Stand: Frequently Walk: Frequently
Responsibilities:
DESCRIPTION OF DUTIES:
1. Ensure the maintenance of quality patient care.
A. Contact patients to assist in setting up services including but not limited to the following: surgery, rehabilitation, oncology, radiation, outpatient laboratory or diagnostic testing, and infusion appointments.
B. Work with patients, providers, and other departments of North Oaks Health System to set goals for the patient’s care.
C. Provide navigation for patients by addressing any logistic barriers, scheduling complications, transportation needs, etc., that would prevent a patient from showing up or completing their appointment in a timely manner.
D. Review patient medical records for medical necessity documentation.
E. Facilitate Peer to Peer reviews.
F. Perform ongoing review of insurance guidelines related to coverage, benefits, medical necessity and authorization processes for outpatients and inpatients.
G. Initiate Pre-service authorization denial appeals.
H. Guide patients to the financial services department and other resources to address any relevant insurance concerns or issues.
I. Educate providers as needed to develop documentation that supports the medical necessity of services.
J. Act as a liaison with provider offices.
K. Review and validate/finalize complex out of pocket responsibility estimates for scheduled surgical services/procedures.
L. Perform high level review of lead days to guide team assignment prioritization.
M. Maintain regular and consistent communication with the ordering provider and other important care team members to best coordinate patient’s care and needs.
N. Document every intervention and interaction into EPIC.
O. Develop and maintain a strong working relationship with other departments (IE case management, surgery, radiology, etc.) within North Oaks Health System as well as external providers, and create a culture for patient-centered care and urgency for our patients.
P. Work with medical interpreters to reach patients of other languages if necessary.
Q. Promote department and facility program development as needed.
R. Ensure orders are available for follow up care and assists in obtaining new and corrected provider orders as needed.
S. Develop improvement processes and correct any variances in accordance with management.
T. Maintain working knowledge of payer specific authorization guidelines as well as Medicare LCD/NCDs, Authorization program, MSPQ criteria, Inpatient only list and ABN processes.
U. Work with IT/Clinic Management to improve and enhance EHR functionality and workflows.
V. Serve as a mentor/educator for non-clinical team members.
W. Use escalation measures to ensure timely patient access to care.
X. Facilitate the attainment of payer retro-authorization by performing clinical review of the record.
Y. Assist in scheduling of surgeries and other tests/procedures/services as applicable.
Z. Facilitate appropriate patient follow up.
AA. Maintains regular conversation with team members to best coordinate patient’s care.
BB. May be responsible for submitting, maintaining, interpreting, and reporting registry data.