Primary Function/General Purpose of Position
Position is accountable for evaluating, clarifying, and determining the financial risk involved for the Market-wide program, including the physicians, and patients as services are required. This includes determining the patient’s benefits available for evaluation, pre-service maintenance, admission, and post-service follow-up care; obtaining inpatient and outpatient authorizations for hospital and physician services; and ensuring necessary communication occur between the payor, and the hospital for appropriate and accurate billing and reimbursement of services.
Essential Job Functions
Obtains, clarifies, and documents the timely receipt of financial authorizations and benefits of patients requiring evaluations, hospitalizations, and all other related inpatient or outpatient services.Determines scope of patients’ benefits including but not limited to coverage for hospital, physician, outpatient, pharmacy, home health, organ procurement, rehabilitation, and Durable Medical Equipment services.Obtains necessary authorizations for hospital and physician services to be provided either in the inpatient and outpatient setting. Transmits the verification numbers and billing information to the appropriate financial and pre-auth departments and the various physician offices.Performs re-certification on all inpatients, coordinating communications between the clinical coordinators, physicians, social workers, the hospital utilization review coordinators, the patient/family, and the payor.Ensures interactions with third party payors case manager and contraction managers occur timely, accurately, and professional. These activities included but are not limited to:Initiates discussions with payor regarding any need for and individual contract to be negotiated as patients are referred to the program center, hospital or other location. Notifies appropriate managed Care specialist who will negotiate with payors as necessary.Performs written correspondence to payors to obtain and to send information and letters of medical necessity and participates in on-site payor visits to the program center.Monitors and identifies changes in regulations and legislation with regard to Medicare of third-party payor reimbursement and updates program director(s) Medical Directors, and any other necessary administration in a timely manner.Assist in the ongoing education of department staff regarding updates in contracts, Medicare reimbursement, and outside resources available to patients.Presents in-services to staff, hospital financial staff, and physician office staff regarding managed care updates and assists in development and implementation of communications systems to send and to receive clinical and financial data between the program center and Patients referring physicians, treating physicians, and payors.Participates in necessary professional organization, meeting, etc. to remain current of financial and reimbursement issues that may impact patient care.This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job-related duties as required by their supervisor, subject to reasonable accommodation.
Licensing/Certification
None
Education
Bachelor of Science Nursing, Education/Healthcare Administration or other related field (required)
Work Experience
3 years’ experience in clinical health care patient accounting, admitting, utilization review, quality assurance or case management (required)
5 years’ experience in clinical health care patient accounting, admitting, utilization review, quality assurance or case management (preferred)
Patient Population
Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served on his or her assigned unit.
Demonstrates knowledge of the principles of growth and development of the life span and possesses the ability to assess data reflective of the patient's status and interprets the appropriate information needed to identify each patient's requirements relative to his or her age, specific needs and to provide the care needed as described in departmental policies and procedures.
Infant (1-12 months)
Pediatrics (1-12 years)
Adolescents (13-17 years)
Adults (18-64 years)
Geriatrics (65 years and older)
Working Conditions
Periods of high stress and fluctuating workloads may occur.
General office environment.
May have periods of constant interruptions.
Required to car travel to off-site locations, occasionally in adverse weather conditions.
Prolonged periods of working alone.
Physical Requirements
Physical Demands
Frequency 0% 1-33% 34-66% 67-100%
Lifting/ Carrying (0-50 lbs.) X
Lifting/ Carrying (50-100 lbs.) X
Push/ Pull (0-50 lbs.) X
Push/ Pull (50-100 lbs.) X
Stoop, Kneel X
Crawling X
Climbing X
Balance X
Bending X
Work Position
Frequency 0% 1-33% 34-66% 67-100%
Sitting X
Walking X
Standing X
Additional Physical Requirements/Hazards
Physical Requirements
Manual dexterity (eye/hand coordination)
Hear alarms/telephone/audio recordings
Reach above shoulder
Finger Dexterity
Acuity – far
Acuity – near
Skills
Medical terminology
Analyze data or information
Budgeting and finance acumen
Possess organizational, problem-solving and critical thinking skills
Word processing/Excel spreadsheet acumen
Healthcare accounting
Group facilitation skills
Relationship building
Attention to detail
Communication with colleagues and professionals
Conflict resolution
Many of our opportunities reward* your hard work with:Comprehensive, affordable medical, dental and vision plans
Prescription drug coverage
Flexible spending accounts
Life insurance w/AD&D
Employer contributions to retirement savings plan when eligible
Paid time off
Educational Assistance
And much more
*Benefits offerings vary according to employment status
All applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, genetic information, or protected veteran status, and will not be discriminated against on the basis of disability. If you'd like to view a copy of the affirmative action plan or policy statement for Mercy Health – Youngstown, Ohio or Bon Secours – Franklin, Virginia; Petersburg, Virginia; and Emporia, Virginia, which are Affirmative Action and Equal Opportunity Employers, please email recruitment@mercy.com. If you are an individual with a disability and would like to request a reasonable accommodation as part of the employment selection process, please contact The Talent Acquisition Team at recruitment@mercy.com