Department: Referral and Authorizations - SRMC

FTE: 0.80
Full Time
Shift: Days

Position Summary:
Responsible for the coordination of appointments and support services for departments/physicians. Interface with insurance companies and other payors on prior authorization and referral requests, abstract charts and assign CPT, ICD and HCPCS codes for purposes of obtaining prior authorization. Assist billing personnel with preparation of denials and submitting appeals for payment. Assist in resolving patient problems, concerns and complaints; serve as patient advocate and liaison, interface with patients, families, staff and department/physicians. Serve as a role model to promote organizational values, a positive work environment and efficient, quality patient care. Ensure adherence to Hospitals and department policies and procedures. Patient care assignment may include neonate, pediatric, adolescent, adult and geriatric age groups.

Detailed responsibilities:
* PATIENT SAFETY 1 - Follow patient safety-related policies, procedures and protocols
* PATIENT CARE - Assist patients in locating departments; schedule and coordinate patient appointments; refer patients and families to appropriate services and resources
* CUSTOMER SERVICE - Identify Primary Care Physicians for all patients and communicate with the PCP as necessary; take messages for department personnel
* CUSTOMER SERVICE - Acquire prior patient records, patient billing, referral information and lab results
* CUSTOMER SERVICE - Assist referring providers in resolving problems, locate UNM physicians and forward documents
* PATIENT SAFETY 2 - Demonstrate proactive approach to patient safety by seeking opportunities to improve patient safety through questioning of current policies and processes
* PATIENT SAFETY 3 - Identify and report/correct environmental conditions and/or situations that may put a patient at undue risk
* PATIENT SAFETY 4 - Report potential or actual patient safety concerns, medical errors and/or near misses in a timely manner
* PATIENT SAFETY 5 - Encourage patients to actively participate in their own care by asking questions and reporting treatment or situations that they don't understand or may 'not seem right'
* PATIENT CARE - May assist clinical staff with routine non-invasive patient treatment procedures and initial screenings
* LEAD - May exercise functional and technical lead over lower level staff
* PRIOR AUTHORIZATION - Complete pre-screening process for specialty clinic appointments for referral and/or prior auth
* PRIOR AUTHORIZATION - Verify coverage eligibility on patients needing prior authorization
* CODING - Abstract chart information and assign CPT, ICD, and HCPCS codes for purpose of predetermination or prior authorization
* LIAISON - Perform as liaison between clinic staff, providers, and the insurance company or other payors to coordinate financial benefits/ coverage and prior authorizations
* DOCUMENTATION - Complete and fax paperwork and pertinent medical documentation to insurance companies and other payors for approval; document final prior authorization in financial systems
* FINANCIAL ASSISTANCE - Refer self-pay patients for financial assistance; make financial assistance appointments
* COORDINATION - Coordinate with hospital and clinic surgical representatives, providers, and other applicable areas for day surgery prior authorization and/or financial coverage or assistance
* TRAINING - Perform outreach/training with clinical areas to ensure process flow remains tight and to maintain open communication
* DENIALS - Track and investigate payment denials due to 'no authorization'; report detail information to supervisors and work with billing office representatives to coordinate appeal efforts
* PATIENT CENTERED MED - Adhere to and promote the core expectations of the Patient Centered Medical Home or Patient Centered Specialty Practice as applicable

Qualifications

Education:
Essential:
* High School or GED Equivalent

Experience:
Essential:
2 years directly related experience
Nonessential:
Bilingual English, Spanish, Keres, Tewa, Tiwa, Towa, Zuni, or Navajo

Credentials:
Essential:
* Not Applicable/Not Required

Physical Conditions:
Sedentary Work: Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

Working conditions:
Essential:
* No or min hazard, physical risk, office environment