Payor Specialist

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Collaborates with the Supervisor/ Utilization Management Coordinators/ (UM Coordinators) and/or Utilization Review Nurses (UR Nurses) to provide specific clinical information to third party payors; responsible for timely provision /flow of clinical information to/from third party payors and Supervisor/UM Coordinator/UR Nurses to ensure certification/approval of hospitalizations.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1.High School Diploma or equivalent.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1.Associate or advanced degree.

EXPERIENCE:

1.Two years of experience in healthcare.

2.Payor relations experience.

3.Clerical experience.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.

They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1.Effectively communicates clinical information with payor to obtain authorization for appropriate level of care and length of stay and documents interactions.

2.Provides prompt feedback regarding payor determinations to Supervisor, UM Coordinators, and/or UR Nurses.

3.Effectively communicates clinical denials to the Physician Advisor Team.

4 Provides prompt follow-up with the Payor to ensure current authorization and accurate payment for the patient's stay.

5 Identifies concurrent denials by third party payor and notifies UM Coordinators/UR Nurses for immediate intervention.

6.Proactively communicates any change in payor information to UR Nurses.

7.Verify with patient financial counseling that all payment sources have been explored and updated in the patient's electronic medical record (EMR).

8.Facilitates denials based on medical necessity, includes completion of necessary documentation and coordinates with Appeals Department.

9.Acts as a liaison to share patient-specific insurance and updates to pertinent areas.

10. Collaborates with Financial Services regarding all incoming retrospective denials and the distribution of denials as well as tracking and trending.

11. Ensures payor and customer satisfaction through effective communication and positive customer service skills at all times.

12. Maintains confidentiality of communications.

13. Maintains, updates, and disseminates payor grid.

14. Maintains assigned Work Lists and Work Queue 's.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.Prolonged standing, or sitting may be required.

2.Visual acuity must be within normal range.

3.Must have manual dexterity to operate keyboards, fax machines, telephones, and other business equipment.

4.Must have reading and comprehension ability.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.Must be capable of performing assigned task despite frequent interruptions.

2.High volume, fast paced environment.

3.Must be capable of working within a shared office space and under fluorescent lighting.

4.Must have ability to maintain concentration in and around noise from office machinery such as a copier or printer.

SKILLS AND ABILITIES:

1.Possesses excellent interpersonal communication and negotiation skills in interactions with patients, families, physicians, and healthcare team colleagues.

2.Knowledge of third party reimbursement or utilization management skills.

3.Effective time management and organizational skills with attention to detail.

4.Knowledge of ICD10/CPT Coding or Medical Terminology.

5.Must have the ability to move throughout the work area.

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Non-Exempt)

Company:

SYSTEM West Virginia University Health System

Cost Center:

544 SYSTEM Patient Financial Services

Address:

Brooke County

Wellsburg

West Virginia