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Payor Specialist - Utilization Review - Full Time - Days

Toledo, Ohio
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The Payor Specialist is responsible for assisting members of the Care Coordination team with coordination of a patient admission or discharge. This role may include but is not limited to the following: communication of information to insurance providers, ensure registration status correctly matches physician orders in defined units, assisting with coordination of the discharge plan, obtaining payor authorization for hospital stay and/or homecare and/or DME benefits. This is accomplished through coordination, collaboration and communication with the insurance carrier, ancillary staff, the utilization review nurse, discharge planner, social worker and patients/family members/care providers.

1. Performs clerical support functions for the Care Coordination department

2. Effectively communicates clinical information with payors via phone, fax, and computer system per payer contract to obtain authorization for appropriate level of care and length of stay as needed.

 3. Responsible for converting registration status to meet medical necessity and documenting same in account notes.

 4. Provides prompt feedback regarding payor determinations to UR Coordinator, Social Worker or Discharge Planner.

5. Transcribes, routes, and maintains all correspondence for the department

 6. Possess the ability to obtain authorization for admission / concurrent stay for designated units.

7. Receives, channels and coordinates all requests for services which are within jurisdiction of the department.

8. Communicates with A/R, denials department, finance department and medical records to render appropriate information needed to secure reimbursement dollars.

9. Maintains confidential information including patient activity information.

10. Communicates and collaborates with team members any concerns related to treatment/care provided

11. Promotes a sense of continuity of care and a climate of concern for individual patient/family welfare.

12. Communicates and collaborates with patient/family members in order to maximize and exercise the use of insurance/Medicare/Medicaid benefit.

13. Cognoscente of current trends changes in UR/UM, and discharge planning.

14. Compliant with HIPPA and patient confidentiality regulations.

15. Performs other duties as assigned.

 1. Must have four or more years of secretarial experience, professional secretaries designation preferred. Must have knowledge of Microsoft Word, Excel and Access. Must exhibit behavior consistent with mission, vision and values of ProMedica Health System. Previous UR/UM and/or discharge planning experience preferred. Knowledge of insurance guidelines, federal regulations and community resources preferred. Strong interpersonal skills required.

 2. Must be able to move about hospital and between workstations; and prolonged periods of standing.

3. Must be able to understand directions, communicate and respond to inquiries in an accurate and timely manner.

4. Must have excellent interpersonal and communication skills, must exercise professional behaviors.

5. Must consider the role as part of a multidisciplinary team, with teamwork approach to patient care.

6. Must be able to input and retrieve information from computer, operate a fax, phone and copy machine.

7. Must be able to address multiple priorities in a timely manner.

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