Care Management Payor Specialist

The role

This person facilitates the exchange of clinical information and authorization between the hospital and third party payors. They provide direct support to the utilization review process.

What you will do

• Reviews Case Managers daily work list to identify clinical reviews due to the payor.
• Reports trends in Case Managers failing to provide timely reviews to Care Management leadership.
• Communicates medical record clinical information to payors to obtain authorization.
• Verifies the payor responds to the clinical update provided.
• Contacts payor if a response is not received.
• Initiates action when a discrepancy in admission status, authorization number or need of clarification is identified.
• Communicates with Case Manager, Care Management leadership, Physicians or Physician Advisors when concerns require assistance.
• Assures the Case Manager is kept informed of determinations.
• Obtains insurance authorization and submits timely clinical information and feedback to the Payors and Care Management nurses.
• Completes Medical Assistance 3808s.

Required qualifications

• High school diploma or equivalent.
• One year work experience to include billing/collection experience and/or experience with Medicare, Blue Cross and Medicaid.

Benefits

• Medical, Dental, and Vision Insurance
• Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year)
• Paid Time Off
• Tuition Assistance Benefits
• Employee Referral Bonus Program
• Paid Holidays, Disability, and Life/AD&D for full-time employees
• Wellness Programs
• Employee Assistance Programs

About the company

Luminis Health.