Smilow Fin Pre Denials Liaison

Yale New Haven Health•New London, CT

About The Position

Under the direction of the Business Operations Manager, this position assures that patients at Waterford & Westerly Smilow get services needed related to oncology/hematology care plans administered at the Cancer Center, as well as supporting diagnostic imaging or other outpatient procedures ordered by the attending, and that the Hospital is paid for those procedures/services. This position will work collaboratively with Financial Clearance, providers and nursing teams to respond to up front denials for treatments and/or imaging procedures for clinical reviews and coordination of peer-to-peer reviews. This position will work as requested with Denial Analysts to reach resolution via appeals and provider rep contacts. This position will screen oncology patients for financial insecurities and provide out-of-pocket estimates. Assists with strategies to reduce future denials and helps facilitate operational changes to improve net revenue and reductions in denials.

Requirements

Previous prior authorization experience required
General knowledge of hospital billing and collection practices
Third party reimbursement methodology with emphasis on governmental payors
Strong analytical skills
Excellent oral, written, and customer service communication skills are required
Knowledge of CPT and ICD-10 coding and medical terminology
Medical record review experience required
Proficient use of personal computers, Epic, Mosaiq, MS Word, Excel and Internet Explorer applications
High School Diploma/GED
2 years of oncology related experience
Previous prior authorization experience required
Must have strong analytical skills
Excellent written/oral and customer service communication skills
Proficient use of personal computers, EPIC, Word, and Excel
General knowledge in hospital billing and collections practices
Third party reimbursement

Nice To Haves

Bachelor's degree in business, information technology, finance, or a related field
Two (2) years of oncology related experience preferred

Responsibilities

Responsible for verifying and ensuring any treatment performed at the Waterford or Westerly Cancer Center(s) or diagnostic imaging or outpatient procedure ordered by a Cancer Center attending provider has been authorized by the insurance company
Assures continued reimbursement through timely and effective referrals, authorizations and communication between the clinical staff and payors
Conducts investigations to determine root cause or initial denials, assesses coverage, coding and/or medical necessity compliance, conducts clinical documentation review, and/or by discussions with the applicable payor
Performs fast appeals by preparation of response to payers through appeal or medical necessity letters or clinical documentation to justify imaging, procedure or treatment regimens
Coordinates and facilitates peer-to-peer reviews
Conduct financial screening for oncology patients to identify underinsured or indigent patients
Provide patients with estimates for out-of-pocket costs, as requested
Recommends procedural changes to improve or to educate clinical and support staff on the authorization process
Acts as a liaison with Denial Analysts for appeals, collaborating with Physicians, clinical staff, governmental agencies, payors, and other Hospital departments as needed
Maintains current knowledge of regulatory and payor requirements to perform job responsibilities
Screens and refers applicable cases in need to financial counseling
Enters clear, concise notes concerning insurance authorization, appeal, denial status in Epic
Meets performance expectations for customer service, teamwork, resource utilization, and staff/self development as outlined in the performance review
Performs other duties as assigned or directed to ensure smooth operation of the department/unit
This position will not supervise anyone. However, the position does require a significant amount of collaboration and communication with insurance companies, physicians, oncology clinical staff, denial management and HIM