SUMMARY: Under the general supervision and within established hospital and departmental policies and procedures, to serve as a liaison between Brown University Health Rheumatology, patient and family members to determine the patient’s portion of medical expenses and ascertain, develop and secure resources which may be available to patient and family members for the resolution of medical expenses incurred. Obtains and verifies coverage authorizations for referrals, medications, and procedures, ensuring financial clearance from insurance companies have been received as well as coordinating the insurance denial process. Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers and one another. In addition to our values, all employees are expected to demonstrate the core Success Factors which tell us how we work together and how we get things done. The core Success Factors include: Instill Trust and Value Differences Patient and Community Focus and Collaborate RESPONSIBILITIES: Assumes an advocacy role with patients and or families and their surrogates regarding the resolution of outstanding patient accounts. Arranges and negotiates payment conditions and plans and advises and counsels patients regarding available resources from which payments can be made. Interviews patients and family members relative to their financial and dependency status or other factors, which may help promote eligibility for medical assistance or other state and federal programs. Secures legal counsel and aid for patients and families. Assists patients in obtaining documentation necessary to apply for public assistance. Assists patients with fair hearing appeals if denied public assistance. Maintains a continuing review of files, records and other forms of documentation on state and federal programs and regulations. Verifies patient insurance coverage (both primary and secondary) online or by telephone. Obtains and verifies coverage authorizations for scheduled and unscheduled patients, to include all sources such as Worker’s Compensation, Medicare Secondary Payer (MSP), Medicare liability, liens, etc. Establishes level of insurance benefits and expected payment for selected services. Determines the patient’s portion of payment, when applicable, and communicates to patient. Ensures referrals are obtained and confirms accuracy of the Primary Care Physician (PCP). Reviews variety of reports and records to ensure that referrals and pre-authorizations from insurance companies have been received. Confirms patient eligibility with insurance carriers and obtains visit authorizations as necessary. Contacts third party payers to obtain pre-authorizations in accordance with established policies. Collaborates with physicians and mid-level providers to schedule peer-to-peer discussions to obtain prior authorization of services denied by the patient’s insurance. Coordinates all information for managing insurance denials. Collaborates with various Brown University Health personnel to resolve billing issues, prior-authorizations, denials, and insurance denials/write-offs. Regularly participates in business team meetings with staff and management to make recommendations where there are perceived problems. Performs other duties as required to support the operations of the department, including, but not limited to, registering patients, scheduling appointments, scanning and faxing documents. MINIMUM QUALIFICATIONS: BASIC KNOWLEDGE: Knowledge of third-party coverage, prior authorization process, referrals, etc. Current knowledge of state and federal resources available for needy and disabled, including familiarity with forms and documents necessary to file appeals on denied claims. Demonstrated interpersonal skills to effectively communicate with patients, family members, Brown University Health employees, third party payers and state and federal representatives and other government service agencies. Ability to operate a computer to access information and to prepare and maintain related records and reports. Possess strong medical terminology knowledge and clear knowledge of Current Procedural Terminology (CPT), International Classification of Diseases (ICD), and registration information. Strong organizational skills to effectively plan, direct, and manage high volume of orders requiring prior authorization. Analytical skills to evaluate effectiveness of workflow, make recommendations for change and to develop, review and evaluate various records and reports. EXPERIENCE Two years progressively responsible experience in health care with a heavy emphasis in one or more of the following areas: patient care environment, health care operations, database management, prior authorizations, referrals, documentation, and departmental operations. Knowledge of coding in a healthcare environment is a plus. Excellent analytical and critical thinking skills and a focus for detail is needed. WORK ENVIRONMENT AND PHYSICAL REQUIREMENTS: Sitting for long periods of time at a workstation utilizing a computer and telephone. May have to do light walking. Ability to lift up to ten pounds. INDEPENDENT ACTION: Performs independently within the departments policies and practices. Refers specific complex problems to the supervisor when clarification of departmental policies and procedures are required. SUPERVISORY RESPONSIBILITY:None.

Pay Range:

$20.96-$34.61

EEO Statement:

Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.

Location:

LPG-Pawtucket-407 East Ave - 407 East Avenue Pawtucket, Rhode Island 02888

Work Type:

m-w 8-5 pm

Work Shift:

Day

Daily Hours: 

8 hours

Driving Required:

No