Clinical Reimbursement & Utilization Coord

Become Rooted in Caring for Life at St. Camillus!

We are currently seeking a Full-Time Clinical Reimbursement & Utilization Management Coordinator

Responsibilities:

The position functions as the liaison between the St. Camillus interdisciplinary team, St Camillus Business Office, and all third-party payers. The position will work collaboratively with nursing, social work, health information management, business office, physicians, patients, and insurance companies to ensure the best utilization of SNF benefits through Medicare A, Medicare B, Medicare Part C, and other third-party payers. It is responsible for ensuring compliance with payer requirements, including prior and concurrent authorizations. Additionally, this position will contribute to coding diagnoses upon admission, provide insurance cut communication notices, manage the commencement of the audit process, and, as directed, participate in strategic reimbursement activities.

• Responsible for managing concurrent authorization requirements for Managed Care Insurances, including Medicare Advantage Plans, Medicaid Plans, the VA, and Commercial Insurance Plans across all levels of care, including Brain Injury, Short Term Rehabilitation, and Continuing Care.
• Submits required medical record documentation and required insurance forms to the individual payers promptly to complete all insurance concurrent reviews to achieve continued authorization for the patient's appropriate level of care.
• Routinely reviews the patient/resident medical record to check that the insurance documentation requirements are met to ensure reimbursement of the patient's current level of care. Communicates with and educates the IDT on the insurance requirements for authorization.
• Functions as the primary contact for insurance inquiries related to level of care and ensures that all requested documentation is provided to the insurer by requested review dates.
• Documents insurance authorization information and other pertinent financial information related to the patient's continued stay in PCC financial notes.
• Obtain Medicare Part B authorizations as required.
• Knowledgeable of existing payer contracts, as well as non-contracted payer guidelines, including level of care requirements, reimbursement methodology and claim appeal process. This includes Medicare, Medicare Advantage Plans, Medicaid, Managed Medicaid Plans, the VA, and Commercial Insurance Plans.
• Remains knowledgeable in the CMS beneficiary notice initiative (BNI), facilitates insurance cuts including the issuance of proper notice (ABN’s and NOMNC’s), and is responsible for presenting notice to the patient/family along with explaining the associated appeals process and coordinating acknowledgement/ signature.
• Participates in the coordination of the Commence appeal process as required, including the gathering and submission of requested/ supportive medical documentation.
• Communicate all information relevant to insurance coverage and payment to the Business Office.
• This includes identifying patients/residents who may need to start the Medicaid application process.
• Participates in routine daily/weekly patient rounds /case management meetings with Business Office, Social Work, Therapy, and providers to communicate current payer status and anticipate changes or cuts in level of care which may affect reimbursement. Anticipates coverage limitations and keeps team members informed of status of insurance coverage.
• Assists the Business Office with claims issues, such as authorization dates and payment denials. As directed, will participate in facility denial management endeavors.
• Will participate in and provide data for identified department “key performance metrics” (KPI) reporting.
• Assist with fulfilling Medical Record pulls for third parties; example: attorney requests and insurance audits under the supervision of the department director
• Review and assign ICD-10 diagnosis codes for incoming admissions and physician billing sheets in accordance with CMS, payer, and facility coding guidelines.
• Responsible for employee injury prevention, follows safety rules, and addresses safety issues with supervisor.
• All other duties as assigned by supervisor.

Qualifications:

• Preference of a minimum of 2 years’ experience in an acute care or rehab setting with case management/discharge planning experience. Additionally, knowledge of Medicare, Medicaid, and Managed Care medical necessity requirements; proficiency in Excel and Word; must be organized, have strong customer service skills, as well as critical thinking and problem-solving skills.
• Associate degree required; Bachelor's degree preferred.
• RN, LPN, HIM, RHIT, RHIA, CCS, CPC, or equivalent healthcare reimbursement experience preferred.

Employee Benefits:

• • No Mandated Shifts
  • Daily Pay
  • Generous PTO Structure for Full Time employees
  • Health/Health Reimbursement Account/Dental/Vision Plans available
  • Company Provided Life Insurance for Full Time employees
  • Retirement Plans
  • Tuition Reimbursement
  • On the Centro Bus Line
  • Free parking

Why work at St. Camillus?

Our Mission: St. Camillus is a non-denominational, not-for-profit organization dedicated to caring for life through a broad range of health care services.

Our Vision: To be the provider of choice for compassionate and innovative care.

If you are interested in joining a team of professionals who are committed to providing high quality services in a caring environment, we want to hear from you!

To learn more information about St. Camillus, visit our website at: http://www.st-camillus.org

EOE/Affirmative Action Employer