SUMMARY:

Under the general supervision of the Practice Manager, responsible for the integrity of department insurance prior authorization process. Coordinates and arranges for all visits, procedures, drug orders, infusions, radiology orders, follow-up patient referrals, ensuring day hospital patient financial clearance from insurance companies have been received as well as possible trouble shooting as needed. Has a clear knowledge of Current Procedural Terminology (CPT), International Classification of Diseases (ICD), and registration information. Analyzes and provides process improvement updates and/or recommendations to the department manager.

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.

RESPONSIBILITIES:

• 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.

• Ensures that all physician orders are complete, legible and scanned within the electronic medical record for viewing. Arranges for and obtains all appropriate documentation from referring physician Conducts Peer to Peer discussions between the insurance Medical Director and Provider.

• Coordinates all information for managing insurance denials.

• Regularly participates in business team meetings with staff and management to make recommendations where there are perceived problems.

• Reviews variety of reports and records to ensure that referrals and pre-authorizations from insurance companies have been received; also reviews for appropriate authorization to notify registration.

• Ensures staff is made aware of changes in hospital or third-party procedures; ensures appropriate training and adherence to approved policies and processes directly or through supervisory staff.

• Confirms patient eligibility with insurance carriers and obtains visit authorizations as necessary.

• Provides mature, quality customer service to patients, their families and /or their representatives.

• When necessary, contacts agencies outside the hospital to obtain pertinent patient information and to coordinate clinic/treatment programs.

• Contacts third party payers to obtain required pre-authorizations in accordance with established policies.

• Returns phone calls to patients, physician offices and other medical providers including but not limited to laboratory and radiology facilities.

• Collaborates with various Brown University Health personnel in order to resolve billing issues, prior-authorizations, denials and insurance denials/write-offs.

• Performs all duties in accordance with Brown University Health’s mission.

MINIMUM QUALIFICATIONS:

BASIC KNOWLEDGE:

• High School diploma or equivalency required.

• Level of knowledge of business systems, office procedures, and computer database and basic computer skills normally acquired through completion of one-year post-secondary business program, or the equivalent.

• Possess strong medical terminology knowledge.

• Strong organizational skills to effectively plan, direct and manage high volume of orders requiring prior authorization.

• Interpersonal skills to train and coach staff and to demonstrate effective customer relations and communications with others within and outside the Hospital.

• Analytical skills to evaluate effectiveness of workflow, make recommendations for change and to develop, review and evaluate various records and reports.

• Ability to operate personal computer, including keyboard skills and familiarity with computer networks. Clerical skills to demonstrate and/or perform activities with staff and providers.

• Ability to recognize and understand clinical documentation pertinent for obtaining prior authorizations.

EXPERIENCE:

• Two years progressively responsible experience in health care with a heavy emphasis in one or more of the following areas: patient care environment, healthcare operations, database management, 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.

SUPERVISORY RESPONSIBILITY:

• None.

Pay Range:

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.

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