Position Purpose:
Under the direction of department supervisor, the position provides constant monitoring of inpatient and observation claims to ensure accurate and timely billing submission to decrease the bill holds related to authorizations. This includes but is not limited to, clinical submission to the payers, securing an authorization for the visit type, continuous follow up with payers for authorizations and/or additional information, and basic reporting for payer specific behaviors. This also requires the Claim Coordinator to monitor payer trends and use Microsoft office to track and report out data for Senior Management.
This position reports to the Department Manager and provides supervision to the Utilization Management Analysts.

Key Job Activities:

• Daily reviews of assigned inpatient/observation work queues to ensure the identified payer source has been notified and initial clinical has been submitted.
• Ensures that initial clinical is submitted and documented in Epic communication appropriately. This includes the payer representative spoken to, documented clinical requirements including the type of submission (fax, email, etc.) and the specific dates for which information was submitted.
• Monitors the patients daily without an approved authorization and contacts the payer until an authorization has a final outcome. Escalates the case to management as needed.
• Documents all actions taken related to the account in Epic. Documented notes are to include but are not limited to, telephone number called, person spoke with, description of conversation, description of medical records submitted, authorization number, reference or call numbers associated with the call, approval/denials.
• Reviews the Sinai DNB hold WQ in Epic for patients that have been discharged without a final status from the payer. No case should be on hold for more than 21 days from the date of import into the discharge WQ. If the case cannot be resolved in the required timeframe, the case should be escalated to management.
• Maintains a working knowledge of various payer notification and documentation requirements.
• Monitors the central utilization faxes to ensure all faxes have been reviewed and documents in the communication section. Escalates any time sensitive request for clinicals and denials promptly. Completes all faxes by end of day.
• Reviews patient status changes daily to ensure that the notification of admission has been completed for each level of care and that the steps above pertaining to clinical and authorization have been followed.
• Supervises and coordinates Utilization Management Analysts and workflows including but not limited to scheduling, ensuring high quality of work that aligns with Sinai Health System Standards.
• Reports issues of concern, suggestions for improvement, identifying payer trends of denials or delays that impact financial clearance to manager.
• Performs quality checks for accuracy, integrity of process and account data while providing feedback to both caregivers and manager; assists manager with development of quality improvement measures, measurements and reports.
• Provides leadership mentoring, ensures an environment that promotes and supports the professional development and growth of caregivers.
• Supports Manager with coordination of staff meetings for the purpose of education, communication of new payer processes.
• Performs other duties as assigned.

Education and Work Experience:

• Associates degree in a related field, but will accept Business Administration, Health Information Management or related degree
• A minimum of 4 years prior working experience with insurance payers, case management, insurance verification or appeals. This includes, but is not limited to, experience working with Physician Advisors, CMOs, and Social Workers.

Knowledge and Skills:

• Must be proficient in using computer application software such as MS Excel, MS Word and various other office-related applications.
• Excellent verbal and written communication skills.
• Must be able to interact with a diverse client base including patients and their family members; medical center staff; and external parties as required.
• High level of organizational and attention to detail skills.
• Ability to follow-through and ensure tasks are brought to successful completion.
• Experience in EPIC and MEDITECH software systems preferred.
  

Certifications/Licenses:

• Medical Assistant or Certified Case Manager Assistant

Workplace Conditions:
PHYSICAL DEMANDS:

• While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle or feel; and talk or hear