Clinical Reimbursement Specialist

Job Description

Overview

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.

At Bridgeport Hospital, we are committed to providing quality medical care and treatment that is coordinated and centered on the patient's specific needs. We strive to achieve benchmarks as a Patient Centered Medical Home and provide health care in a setting where patients are at the center of their care team. All employees of Bridgeport Hospital are part of the patients care team and contribute to the team approach of promoting access, continuous, comprehensive care and work to provide quality improvement in the care provided to their patients.

The Clinical Reimbursement Specialist is responsible and accountable for ensuring the reimbursement of patient care that efficiently and effectively support the desired financial and clinical outcomes. Review medical records for appropriateness and continued length of stay providing supporting documentation to payers to obtain authorizations. Responsible also to collect data on diagnosis and procedures as well as other clinical documentation to appeal payer decisions when necessary. In collaboration with the health care team, the Clinical Reimbursement Specialist ensures that specific financial outcomes are achieved and that processes are appropriately developed and utilized within the designated fiscal time frame to ensure payment. With other members of the health care team, the Clinical Reimbursement Specialist participates in the ongoing evaluation of payment practices, authorization review processes, and the identification of barriers and trends to such aspects of care coordination that support timely and appropriate reimbursement. Through this interaction, the team, and the Clinical Reimbursement Coordinator, work collaboratively toward resolution and process improvement.

EEO/AA/Disability/Veteran

Responsibilities

• 1. Obtains initial information from patients to identify primary and secondary sources of insurance and verifies and authorizes initial services in a timely manner
• 2. With the Clinical team, as well as with independent review of the electronic medical record, reviews patients and provides information to insurance carriers to ensure coverage of continued stay
• 3. Utilizes information obtained from various resources to ensure that each patient meets the clinical needs for admission and ongoing treatment
• 4. Intervenes when necessary to identify trends and consistent barriers to correct delays and eliminate/reduce negative financial outcomes.
• 5. Collaborates with appropriate individuals and departments to ensure appropriate reimbursement
• 6. Facilitates communication within the health care team and LIP to address any issues related to payment/reimbursement for treatment. Collaborates with other departments to identify and document all barriers to access and timely intervention.
• 7. Communicates as needed with payors and governmental contractual agencies regarding patient status/treatment plan to secure the need for admission and thus grant authorization of services. Develop strong working relationships with payors to support collaborative efforts in ensuring hospital reimbursement
• 8. Collaborate with the health care team members and the payor regarding service authorization pending denial activity. Provide written documentation and follow through to support the reversal of payment denials in collaboration with the clinical team.
• 9. Along with other members of the health care clinical and financial team, act as a patient advocate to support ongoing medical intervention and treatment. Exhibit awareness of ethical /legal/confidential issues concerning patient care and treatment and support the adherence to such practice.
• 10. Provides accurate posting to the Payroll System
• 10.1 Maintains exception log used to support the payroll time keeping process to support the biweekly payroll
• 11. Performs miscellaneous duties as required or requested
• 11.1 Provides clinical/clerical suppport to all programs, including insurance verification, authorizations, scheduling, and other duties as requested
• 12. Is knowledgeable in the policy and procedures of the hospital and REACH program. Provides coverage to other staff as needed.

Qualifications

EDUCATION

Bachelors Degree in Psychology or Related Field

EXPERIENCE

A minimum of three years of relevant clinical experience strongly preferred in a psychiatric setting, along with relevant experience in case management, care coordination, and/or utilization management in a psychiatric or insurance setting. Knowledge of finance and billing practices are strongly preferred.

LICENSURE

License preferred

SPECIAL SKILLS

Clinical credibility with physicians, nurses, and other members of the health care team. Strong interpersonal skills to facilitate negotiation for reimbursement and changes in systems /practices. Excellent communication skills with the ability to communicate effectively with multiple clinical and financial disciplines and skill levels. Ability to quickly process problems, identify solutions, and implement action to support desired financial outcomes. Ability to provide financial education balancing clinical needs to colleagues and physicians. Comprehensive understanding in the use of computerized medical record systems to support review activity. Working knowledge of third party and governmental payor prospective payor systems. Comprehensive PC literacy with proficiency in Microsoft word, excel and powerpoint.