Insurance Specialist-6027

Kingman Healthcare•Kingman, AZ

10d

About The Position

Description Staff Position Description Position Title: Insurance Specialist Position Code: SpecCMIns-6027 Department: Case Management Safety Sensitive: Yes Reports to: Director of Case Management Exempt Status: No Position Purpose: All KHI employees are expected to perform their respective tasks and duties in such a way that supports KHI’s vision of providing the region’s best clinical care and patient service through an environment that fosters respect for others and pride in performance. Key Responsibilities [List of material responsibilities and essentials duties which must be completed in achieving the objectives of the position] Primary Payer Contact · Serves as Primary Contact for all payer requests for clinical information and utilization review decisions, in an efficient and professional manner. · Serves as primary contact/intake for all incoming calls from payers on a real time basis–same day as received (when working) and seldom needs assistance. · Documents all calls immediately. · Handles all calls professionally reflecting a positive and collaborative attitude. · Demonstrates understanding of payer sources/requirements. Case Management Duties · Serves as primary communicator to Case Managers when clinical information is required by a payer for pre-certification in a professional, assistive, and collaborative manner. · Consistently communicates and refers patient information to the Case Manager within 30 minutes from receipt of the initial request on all cases where the payer has requested clinical information for pre-certification. · Awareness of case assignments to ensure correct Case Manager is receiving the payer requests. · Utilizes proper channels to resolve conflicts and problems. · Assumes responsibility for knowledge of and adherence to Case Management and KHI Standards, Policies, and Procedures. Information Management: · Obtains and tracks appropriate information from Case Managers/Utilization Review Nurses and transmits to payers via fax, phone, or email, within the timeframe determined by the payer. · Tracks cases to ensure authorization is received from the payer within 24 to 48 hours. · Communicates authorization information to Case Manager/Utilization Review Nurse and updates information into the EMR and ARM module. · Arranges peer to peer conversations with RNs or MDs when requested by payer to facilitate appropriate authorization for services. · Forwards clinical information to the payers when received by end of day. · Communicates to Case Management leadership when a Case Manager is not adhering to the timeframe standard. · Follows-up to ensure that all certification determinations are received within 24 to 48 hours from submitting the clinical information. · Communicates to Case Management leadership when a case has been referred to the payer’s Medical Director, a reduced level of care or denial determination has been received, or if 2 calls have been placed to the payer without response. · Demonstrates EMR and ARM module notes are concise and accurately reflects the activity and outcome. · Tracks cases until discharge and ensures all days are accounted for in EMR and ARM module. · Communicates to Director all concerns, complaints, needs or problems when unable to resolve. Communication: · Communicates final payer outcome to the Case Manager and Business Office. · Communicates to the Case Manager the payer determinations within 30 minutes of receipt of information. · Documents notes in EMR and ARM module, all outcomes from payer certifications.

Requirements

High School Diploma or GED Equivalent
Must have 2 years of experience in a healthcare setting performing related duties such as insurance claims, utilization review, doctor’s office, DME, etc.
Experience with office machines (i.e., copier, fax, telephone), computer terminal/personal computer, software (i.e., word processing, spreadsheets, etc.)
Strong oral and written communication skills as well as excellent interpersonal skills in interacting with payers and healthcare team members

Nice To Haves

Education: Associate degree or higher in business or healthcare related field
Expertise and knowledge of third-party payer requirements and regulations including Medicare/Medicaid, managed care payers, commercial insurance companies, worker’s comp, etc.
Knowledge and expertise in developing and using data management tools such as Excel, Access, etc.

Responsibilities

Serves as Primary Contact for all payer requests for clinical information and utilization review decisions, in an efficient and professional manner.
Serves as primary contact/intake for all incoming calls from payers on a real time basis–same day as received (when working) and seldom needs assistance.
Documents all calls immediately.
Handles all calls professionally reflecting a positive and collaborative attitude.
Demonstrates understanding of payer sources/requirements.
Serves as primary communicator to Case Managers when clinical information is required by a payer for pre-certification in a professional, assistive, and collaborative manner.
Consistently communicates and refers patient information to the Case Manager within 30 minutes from receipt of the initial request on all cases where the payer has requested clinical information for pre-certification.
Awareness of case assignments to ensure correct Case Manager is receiving the payer requests.
Utilizes proper channels to resolve conflicts and problems.
Assumes responsibility for knowledge of and adherence to Case Management and KHI Standards, Policies, and Procedures.
Obtains and tracks appropriate information from Case Managers/Utilization Review Nurses and transmits to payers via fax, phone, or email, within the timeframe determined by the payer.
Tracks cases to ensure authorization is received from the payer within 24 to 48 hours.
Communicates authorization information to Case Manager/Utilization Review Nurse and updates information into the EMR and ARM module.
Arranges peer to peer conversations with RNs or MDs when requested by payer to facilitate appropriate authorization for services.
Forwards clinical information to the payers when received by end of day.
Communicates to Case Management leadership when a Case Manager is not adhering to the timeframe standard.
Follows-up to ensure that all certification determinations are received within 24 to 48 hours from submitting the clinical information.
Communicates to Case Management leadership when a case has been referred to the payer’s Medical Director, a reduced level of care or denial determination has been received, or if 2 calls have been placed to the payer without response.
Demonstrates EMR and ARM module notes are concise and accurately reflects the activity and outcome.
Tracks cases until discharge and ensures all days are accounted for in EMR and ARM module.
Communicates to Director all concerns, complaints, needs or problems when unable to resolve.
Communicates final payer outcome to the Case Manager and Business Office.
Communicates to the Case Manager the payer determinations within 30 minutes of receipt of information.
Documents notes in EMR and ARM module, all outcomes from payer certifications.