Specialty Procedure Coord - PN

Job Summary

Serves as a liaison between the patient, insurance company, internal staff, and outside offices to manage and obtain all pre-requisites and prior authorizations for specialty-specific procedures or surgeries while being the gatekeeper for the final decision of procedure/surgery being scheduled to ensure reimbursement will be received. Coordinates with clinical team to address concerns in patient’s preparation for procedure/surgery. Responsible for overall data collection, reporting of case volume, and other metrics for programmatic initiatives as well as identification of trends and potential concerns such as insurance denials.

Minimum Qualifications

Minimum Education: High School Diploma or Equivalent
Minimum Years of Experience: 4 Years of Insurance Experience in a Medical Office Practice 
Substitutable Education & Experience (Optional): None.
Required Certifications/Licensure: None.
Required Training: Familiar with medical terminology, procedures, and coding;

Extensive knowledge of guidelines required for medical record documentation;

Must be computer literate with extensive knowledge of computer systems, including EHR and MS Applications.
 

Essential Functions

• Works independently as well as closely with members of the multidisciplinary team including but not limited to the surgeons, practice leadership, and quality/programmatic coordinators. 
• Responsible for assisting patients with benefit coordination to assure the appropriate insurance prerequisites are completed in a timely manner. Responsible for collection of pre-payment for procedures/surgeries when applicable.
• Tracks and trends insurance requirements to identify potential issues and act to resolve those problems quickly. Works collaboratively with physicians and managers regarding updating and modifying program pathways to maintain or increase the effectiveness in reimbursement rates, billing and collection. 
• Serves as a liaison between patients, other medical providers, other clinical departments, front business office, and insurance companies regarding authorizations for procedure/surgery. 
• Obtains and verifies appropriate documentation from payers to establish coordination for clean claims. Maintains all informational material received from insurance companies. 
• Stays current on all program requirements and medical necessity requirements in order to provide assistance and guidance to leadership on reimbursement-related matters regarding procedure/surgery requirements. 
• Assists in research and follow-up on all denials, claim corrections, and rejections related to procedure/surgery reimbursement. 
• In collaboration with practice/program leadership, oversees and coordinates team meetings that bring a multidisciplinary approach to address any concern with the surgical patient experience.

Duties & Responsibilities

• Provides education to patients, surgeons and all staff regarding pre-requisites for procedure/surgery as well as the appeal process. 
• Demonstrates knowledge of commercial, Medicaid, Medicare, Workers' Compensation, all contractual third-party payers and other private carriers regarding pre-requisites and authorizations for surgery. 
• Prepares and runs reports related to procedure/surgery volume and other metrics daily, weekly, monthly, and/or as deemed appropriate. 
• Helps maintain the work area in a neat and orderly fashion. Responsible for keeping supplies needed to perform the job. 
• Demonstrates appropriate communication of information to all ages and responds to customer/patient requests and/or needs, i.e., hard of hearing, etc. 
• Acts as a gatekeeper for pre-surgical clearances to assist patients and clinical staff in scheduling and reviewing required documentation. 
• Serves as a liaison with the applicable quality coordinator and the practice to assist with compliance in accreditation requirements and processes for patient care. 
• Manages any retail functions related to the specialty procedure/program if applicable (i.e. for bariatrics, manage the protein product line to include inventory, ordering, product selection, and marketing).
• Manages coordination of any pre or post-operative referrals if applicable; includes referrals/orders for outpatient rehab or home health per physician protocols as well as coordination of any durable medical equipment needed for pre or post-operative care such as braces, boots, slings, crutches, walkers, etc.
• Serves as point-of-contact for attorneys, case managers, and adjusters for any patients covered by workers compensation claims or other third-party claims, if applicable.
• Demonstrates Service Excellence. 
• Performs all other duties as assigned.