Lead Payor Specialist

Responsibilities

• Leads the work of Payor Specialists within the department.
• Serves as a role model and resource to Payor Specialists and other staff regarding Payor Specialists Best Practices.
• Provides training and orienting to all Payor Specialists, and maintains training and orientation materials and records.
• Reviews cases escalated by the Payor Specialists for appropriateness and accuracy of documentation and process.
• Reviews cases escalated by the Quality Utilization Specialists that may have authorization challenges. Further escalates cases as appropriate.
• Coaches Quality Utilization Specialists and Payor Specialists on issues related to payor specifications, obtainment of authorization, and denial coordination.
• Promotes a professional and positive environment. Demonstrates teamwork and effective communication across units/departments and helps resolve operational issues.
• Participates in departmental quality improvement activities. Provides ideas and suggestions for process improvements within the department.
• Partners closely with Managed Care, Patient Access, Social Work and Financial Clearance departments as well external stakeholders.
• Serves as first line of assistance to staff. Investigates and resolves patient, technical and workflow problems related to their area of responsibility.
• Alongside QU leadership, helps coordinate and supervise section staffing to ensure sufficient staff to cover all aspects of service.
• Works proactively with Lead/management to adjust daily staff work assignments due to absences or increased patient volume.
• Assists with data preparation and the creation of presentation materials as needed for the Quality and Documentation Team.
• Collaborates with the QUS staff 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.
• Tracks and assures compliance with payor requests for information and communicates payor requests to appropriate QUS as needed.
• Communicates with and coordinates Onsite Payor Review activities to assure timely certification determinations.
• Documents and communicates denial and peer review information and patient out-of-network status and contact information to the QUS team.

Qualifications

• Bachelor's degree
• Minimum five (5) years of healthcare/related experience
• Conversant with medical terminology
• Expertise and knowledge of third-party payor, Medicare/Medicaid guidelines
• Advanced computer skills including word processing and spreadsheets
• Experience in preparation of training tools and/or work flow design
• Computer and database management skills to efficiently and effectively manage QU Department electronic systems, including Careport and Epic

Preferred

• Master's Degree in healthcare-related field
• 7+ years of relevant experience
• Acquired certifications relevant to position