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The Payer Specialist is responsible for preforming duties of utilization review assisting case managers with patient accounts, patient type, and timely payer authorizations for initial and continued stay. This includes effective communication with payers, case managers, patient access, financial services and a variety of clinical disciplines to capture and maintain accurate account information in STAR and to ensure 3rd party payment. The Payer Specialist is also responsible for managing appeals for denied cases.
Responsibilities
Completes initial/stay reviews/obtains authorization # by obtaining information from the medical record to payer. Puts authorization numbers/account notes in STAR
Demonstrates knowledge of Medicare/Medicaid regulations/various commercial payer requirements
Tracks/assures compliance with payer requests/communicates requests to appropriate staff to prevent denials
Provides feedback for payer guidelines, issues, and trends discovered in communications w/payers/STAR reports. Update staff of changes
Appropriately notifies physicians/manager/case manager of chart deficiencies re: insurance requirements
Reviews charts for retroactive authorizations. Enters numbers/ account notes for billing
Investigates complex payer issues working to resolve preventing costly denials. Works with Revenue Cycle team on root causes of denials/resolve. Initiates appeals of denied cases w/follow up
Works w/RAC Coordinator to identify RAC issues/risk areas. Instructs case management department in RAC activity/adjustments to processes to ensure compliance w/federal regulations
Participates in other Revenue Cycle projects i.e. implementation/installation of new systems/ system upgrades
Resource for software applications/computer communication issues/concerns for department. Takes initiative to research issues
Maintains Kronos timekeeping system
Ensures compliance w/Medicaid certification
Collaborates with physician practices/ancillary departments with accurate info
Responds to inquiries regarding accounts/customers in a timely, courteous manner
Serves as a resource to staff, payers, w/organization. Demonstrates flexibility to changing needs
Responds to payers' requests for more information/clarification promptly thereby mitigating risks of denials. Seeks case manager assistance in questionable accounts
Assists with orientation of staff
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Qualifications
Required Education: High School Diploma, GED, or Equivalent.
Required Experience / Skills: Three (3) years of experience in a healthcare field.
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