Clinical Reimbursement Specialist

Cape Cod Healthcare•Hyannis, MA

About The Position

As a key member of the referral services team, a Clinical Reimbursement Specialist will serve as the primary contact responsible for payer outreach determining a patient’s insurance coverage, benefit details, and authorization requirements upon receipt of a new patient referral. This role involves identifying managed care, high risk, and reduced fee status clients, and maintaining current awareness of insurance coverage benefits and Agency policy. The specialist will manage and navigate managed care insurance policies and procedures to ensure patient coverage, and ensure accurate and timely authorizations are submitted and received with the payer telephonically or electronically. Collaboration with various departments is essential for seamless communication and documentation. The role also includes ensuring prior and re-authorization for services, reviewing clinical documentation for reimbursement, and providing staff education regarding managed care documentation guidelines. Additionally, the specialist will collaborate with clinicians on case management for free care clients, provide insurance information to the Agency Accounts Receivable department, process reconsiderations and appeals of denials, and provide interim reports to third-party payers. Facilitating communication between clinicians, physicians, and case managers, participating in patient case conferences, and expediting the identification of community resources are also key responsibilities. The specialist will also review goals for managed care and free care clients, negotiate optimal reimbursement fees, maintain updated managed care/reimbursement manuals, and interpret Agency policies to various stakeholders. A strong emphasis is placed on providing service excellence and identifying process improvement opportunities.

Requirements

Word processing, data entry, problem-solving, and communication skills are required.
Attention to detail and ability to work in a fast-paced environment.
Excellent organizational and time management skills.

Nice To Haves

Associates degree or equivalent preferred
2 years electronic health medical record experience preferred.
Medical billing experience preferred.
Knowledge of third-party reimbursement and medical terminology preferred.

Responsibilities

Serve as the primary contact responsible for payer outreach determining a patient’s insurance coverage, benefit details, and authorization requirements upon receipt of a new patient referral.
Identify managed care, high risk, and reduced fee status clients and maintain current awareness of insurance coverage benefits and Agency policy related to same.
Manage and navigate managed care insurance policies and procedures to ensure patient coverage.
Ensure accurate and timely authorizations are submitted and received with the payer telephonically or electronically.
Collaborate with various departments to ensure seamless communication and documentation.
Ensure prior and re-authorization for services is obtained as per the individual insurer and maintain documentation of all authorizations for services.
In collaboration with the clinician, review clinical documentation for reimbursement including the parameters established by the individual insurer and the appropriate clinical practice guideline.
Provide individual and group staff education regarding managed care documentation guidelines, and serve as a contact person for Agency staff, insurance representatives, and external and system case managers.
In collaboration with the clinician, provide case management of free care clients during the episode.
Provide timely insurance information to the Agency Accounts Receivable department.
Process reconsiderations and appeals of denials for service, as appropriate.
Review ongoing and retroactive reimbursement issues.
Provide standard interim reports to third-party payers and contracting agents as required.
Facilitate communication between clinician and physicians and third-party case managers regarding the patient’s plan of treatment, as required to ensure quality, appropriate and cost-effective care, and utilization of services.
Participate in patient case conferences as a resource regarding third-party payer issues.
Expedite the identification of community resources and vendors for the Agency field staff and assist in procuring the services and products when necessary.
In collaboration with the clinician, review goals for managed care and free care clients to ensure that the individual patient’s needs are met throughout the continuum of care.
Assist staff identifying strategies to improve resource utilization through the use of clinical practice guidelines and appropriate community resources.
Negotiate optimal reimbursement fees to maximize benefits to the patient and revenues to VNA.
Maintain updated managed care/reimbursement manuals.
Interpret Agency policies and criteria for service to insurers, fiscal intermediaries, patients, families, physicians, and the public.
Consistently provide service excellence to all patients, family members, visitors, volunteers, and co-workers.
Challenge current working practices: identify process improvement opportunities and present recommendations and solutions to management.
Engage and commit to the organization’s culture of continuous improvement by actively participating, supporting, and promoting CCHC Pillars of Excellence.
Other duties as assigned.