Health Insur & Auth Rep III

As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive.

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ESSENTIAL FUNCTIONS

• Reviews each visit for insurance history by utilizing the hospital system along with all third-party payer systems.
• Obtains benefits, pre-certification requirements, and/or completes notification of admissions.
• Documents demographic and insurance information in a timely, accurate manner in the hospital computer system, following department and hospital standards. Identifies and confirms uninsured and underinsured patients for appropriate referral to Financial Case Management for possible Medicaid application and/or Financial Assistance.
• Notifies and monitors patients for completion of adding newborns onto policy. Determines the primary payer through knowledge of Medicare and other payer regulations for the coordination of benefits.
• Notifies Utilization Management of clinical requests by third party payers.
• Maintains a monitoring system for adequate benefit coverage and eligibility throughout the inpatient stay.
• Reviews payer denials and communication from Patient Financial Services related to Financial Counseling responsible areas and performs necessary follow-up to secure payment.
• Notifies and monitors patients COBRA entitlement and assists with paperwork if necessary.
• Monitors current admissions to ensure eligibility and additional clinical requirements.
• Develops a process to monitor caseload, documents thoroughly in the hospital financial system and communicates essential information to appropriate parties in a timely and accurate manner.
• Observes work queue daily for potential cases that may require notification to insurance company and provides within payer designated timeframe.
• Works to identify barriers to securing cases and develop and implements a plan to successfully resolve issues.
• Utilizes resources and investigational skills to solve unique and complex problems.
• Verifies Medicaid eligibility every 30 days for active coverage.
• Reviews Medicare for MSP questions and validations. Investigates and corrects any discrepancy between MSPQ and patient registration.
• Ensures compliance with the Office of the Inspector General guidelines by notifying patients of exhausting Medicare benefits and the option to utilize lifetime reserve days.
• Ensures appropriate documentation is on file for assigned caseload.
• Maintains a thorough knowledge of insurance carriers’ policies and benefit levels as it relates to each specialty.
• Creates a professional and effective customer-oriented environment by utilizing excellent communication skills to obtain pertinent demographic information.
• Confirms insurance information and discuss financial obligation.
• Assists with communication and coordination of activities with multiple areas within the University of Rochester Medical Center System.
• Communicates with external parties such as patients, families, third party payers, Department of Social Services, Department of Health, attorneys, outside hospitals, governmental agencies and external review agencies.
• Explains workflow and policies to areas of impact.
• Provides training and resources to all coverage and those within URMC/affiliates.

Other duties as assigned.

MINIMUM EDUCATION & EXPERIENCE

• High School diploma or equivalent and 2 years of related experience, preferably in a hospital setting required
• Associate's degree preferred
• Or equivalent combination of education and experience

KNOWLEDGE, SKILLS AND ABILITIES

• High degree of professionalism and motivation with excellent communication and customer service skills required
• Strong ability to multi-task and prioritize required
• Flexibility to work weekends, other assigned hours required
• Familiarity with Medical terminology required
• Strong computer skills and ability to type 45 words per minute preferred

The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture to advance the University’s Mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion, creed, sex, sexual orientation, citizenship status, or any other characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law.