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. Identifies managed care, high risk, and reduced fee status clients and maintains 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. Ensures prior and re-authorization for services is obtained as per the individual insurer and maintains 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. Provides individual and group staff education regarding managed care documentation guidelines, and serves as a contact person for Agency staff, insurance representatives, and external and system case managers. Collaborating with the clinician, provides case management of free care clients during the episode. Provide timely insurance information to the Agency Accounts Receivable department Processes reconsiderations and appeals of denials for service, as appropriate. Review ongoing and retroactive reimbursement issues. Provides standard interim reports to third-party payers and contracting agents as required. Facilitates 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. Participates in patient case conferences as a resource regarding third-party payer issues. Expedites the identification of community resources and vendors for the Agency field staff and assists 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. Assists 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. Maintains updated managed care/reimbursement manuals. Interprets Agency policies and criteria for service to insurers, fiscal intermediaries, patients, families, physicians, and the public. Consistently provides service excellence to all patients, family members, visitors, volunteers, and co-workers. Challenges current working practices: identifies process improvement opportunities and presents recommendations and solutions to management. Engages and commits to the organization’s culture of continuous improvement by actively participating, supporting, and promoting CCHC Pillars of Excellence. Other duties as assigned.

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.
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.
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.
Serve as a contact person for Agency staff, insurance representatives, and external and system case managers.
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.
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.
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.
Provide service excellence to all patients, family members, visitors, volunteers, and co-workers.
Identify process improvement opportunities and present recommendations and solutions to management.
Actively participate, support, and promote CCHC Pillars of Excellence.
Other duties as assigned.