Authorization Contract Specialist - CMC Utilization Management - Per Diem - 8 hour - Days
About The Position
The Authorization Contract Specialist is responsible for coordinating and collaborating with the CM/SW leadership on all difficult to place complex cases. This individual is critical to the overall efforts of implementing a complex plan of action and communicating with the entire clinical multi-disciplinary team the coordinated plan related to the financial agreement, Patient Services Letter of Agreements, Invoicing and transportation plans and agreements. The Authorization Contract Specialist is also responsible for investigating legal restrictions and coordinating with JMH Legal Counsel. The Authorization Contract Specialists works closely with Patient Accounts, straight/managed Medic-Cal payors, and CCS to assure timely submission and follow up for authorization of services for the individual patient. The Specialist generates the daily Utilization Review call list for requested medical documentation to provide to payors. The Specialist notifies case managers, utilization review nurses, clinical payment specialist, physician advisors, and CM leadership of insurance denials. The Specialists may assist in coordinating efforts to address payor denials. The Specialist reviews utilization patterns, identifies trends and problem areas, reports and investigates unusual occurrences, and assists in collecting and assimilating clinical data to enhance the quality of services. Further, the Specialist provides relief of other department office coverage as required.
Requirements
- Extensive knowledge of Government and Commercial Payers required including billing rules, regulations and the authorization and review process.
- Excel computer expertise at Intermediate level or higher required.
- A high degree of organizational skills, ability to set priorities, manage multiple demands and the ability to complete tasks under strict time lines is required.
- Excellent written and communication skills including demonstrated ability in composing business letters required.
- Basic computer and typing skills are required.
Nice To Haves
- Bachelor's Degree Relevant Field
- 3-5 years
- Commercial and/or Governmental insurance experience preferred.
- Understanding of authorization process, clinical background preferred.
Responsibilities
- Coordinating and collaborating with the CM/SW leadership on all difficult to place complex cases.
- Implementing a complex plan of action and communicating with the entire clinical multi-disciplinary team the coordinated plan related to the financial agreement, Patient Services Letter of Agreements, Invoicing and transportation plans and agreements.
- Investigating legal restrictions and coordinating with JMH Legal Counsel.
- Working closely with Patient Accounts, straight/managed Medic-Cal payors, and CCS to assure timely submission and follow up for authorization of services for the individual patient.
- Generating the daily Utilization Review call list for requested medical documentation to provide to payors.
- Notifying case managers, utilization review nurses, clinical payment specialist, physician advisors, and CM leadership of insurance denials.
- Assisting in coordinating efforts to address payor denials.
- Reviewing utilization patterns, identifies trends and problem areas, reports and investigates unusual occurrences, and assists in collecting and assimilating clinical data to enhance the quality of services.
- Providing relief of other department office coverage as required.
Benefits
- Competitive salary and benefit package available.
- Employee of the Month
- Employee Suggestion Program rewards
- Employee Success Sharing Program
