Job Description
The PAYOR SPECIALIST reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.
The PAYOR SPECIALIST supports the Clinical Documentation and Quality Utilization team to efficiently communicate with payors and ensure timely initial stay authorization and continued stay authorizations for acute care inpatients. The Payor Specialist collaborates with the Quality Utilization Specialist in order to effectively communicate accurate clinical information to payors to obtain pre-authorization, pre-certification, and continued stay authorization for appropriate levels of care and length of stay.
RESPONSIBILITIES:
- Assists in the communication of clinical information provided by the Quality Utilization Specialist with all payors using a variety of methods, including faxing, payor web entry, and verbal communication.
- Obtains timely payor determinations regarding certification of hospital stay and accurately records and conveys the determination to the Quality Utilization Specialist.
- Tracks and assures compliance with payor requests for information and communicates payor requests to appropriate Quality Utilization Specialist as needed.
- Communicates with and coordinates Onsite Payor Review activities to assure timely certification determinations.
- Documents and communicates denial and peer review information to the Quality Utilization Specialists and the Lead Quality Utilization Specialists.
- Communicates patient out-of-network status and contact information to the Quality Utilization Specialists.
- Ensures inpatient pre-certification is obtained through communications with registration staff in the Patient Access Unit.
- Provides feedback to utilization staff and management as needed regarding payor guidelines, issues, and determinations discovered during communication with payors.
- Ensures payor and customer satisfaction by utilizing effective communication and interpersonal skills.
- Provides entry, tracking, and trending of Quality and Documentation data and outcomes, as directed.
- Participates in Performance Improvement initiatives and performs other Quality and Documentation-related functions, as directed.
- Maintains up-to-date payor contact list.
- Mails out appeals initiated by the Lead Quality Utilization Specialists.
- Distributes and processes payor mail, including but not limited to, authorization and denial letters.
- Upholds the Northwestern Memorial Hospital policy on patient confidentiality.
- Assists with data preparation and the creation of presentation materials as needed for the Quality and Documentation Team.
- Exhibits Patients First behavior to patients, visitors, physicians, and employees. Ensures that the processes on the off-shift, holidays, and weekends are patient driven and efficient. Responsible for identifying quality improvement opportunities of shift operations. Tracks routine measures that are identified as Quality Indicators.