To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values-integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
Under the direction of the Business Operations Manager, this position assures the hospital is paid for services performed at the Cancer Center. This position will ensure that required prior authorization and referrals for specific oncology treatment regimens and procedures are obtained prior to treatment. The insurance specialist will work with denial analysts to bring denials to resolution via appeals and provider rep contacts, assists with strategies to reduce future denials and helps to facilitate operational changes to improve net revenue and reductions in denials.
Responsibilities: 1. Core competency 1.1. Responsible for ensuring any treatment that is performed in the Cancer Center has been authorized by the carrier prior to treatment. Assures continued reimbursement through timely and effective referrals, authorizations and communication between the clinical staff and payers. 1.2. Conducts investigations by reviewing clinical documentation, benefits, eligibility, coding, claims payments, and/or discussing denials with the applicable payer. Screens and refers applicable cases in need to financial counseling 1.3. Recommends procedural changes to improve or to educate clinical and support staff on the authorization and collection processes. 1.4. Acts as a liaison with denial analysts for appeals, collaborating with physicians, clinical staff, governmental agencies, payers and other hospital departments as needed. 1.5. Maintains current knowledge of regulatory and pay requirements to perform job responsibilities. 1.6. Reviews commercial managed care payer websites on a bi-monthly basis, or as needed for specific issues. Maintains a database of managed care requirements for the Cancer Center. 1.7. Performs other duties as assigned or directed to ensure smooth operation of the department/unit.
Bachelor's degree in Business, Information technology, Finance, or a related field. Additional years of experience above the minimum requirements may substitute for educational requirements on a one to one basis (one year of experience equals one year of education)
Two (2) years of related experience required. Previous pre-authorization experience preferred. Knowledge of hospital billing and collection practices, third party reimbursement methodology with emphasis on governmental payers, strong analytical skills and excellent oral, written and customer service communication skills are required. Knowledge of CPT and ICD-10 coding and medical terminology, medical record review experience preferred. Proficient use of personal computers, MS Word, Excel and Internet Explorer applications.