Description
We're a Little Different
Our mission is clear. We bring to life a healing ministry through our compassionate care and exceptional service.
At Mercy, we believe in careers that match the unique gifts of unique individuals – careers that not only make the most of your skills and talents, but also your heart. Join us and discover why Modern Healthcare Magazine named us in its “Top 100 Places to Work.”
Overview:
Responsible for knowing which assistance programs, such as drug copay cards, that patients may qualify for, assisting patients in enrolling in those programs, monitoring services rendered, and billing the assistance programs for the applicable funds. This position requires a thorough understanding of claims programs for the applicable funds.
The Prior authorization representatives are responsible for understanding insurance rules and requirements for tests and different categories of tests ordered to understand how to submit a prior authorization and clinical documentation required to receive an approval.
This position requires a thorough understanding of procedures of prior authorization requests, coding, billing, rejections and denials. It requires monitoring of insurance company regulations for changes in pre-certification, documentation, or claims submission requirements. It also requires accuracy, attention to detail and the ability to communicate well with physicians, staff, patients, and insurance companies. The Prior authorization representative also serves as a resource for other staff and patients, and always performs duties in a manner consistent with Mercy Service Standards. Performs duties and responsibilities in a manner consistent with our mission, values, and Mercy Service Standards.
Qualifications:
- Responsibilities:Productivity (20%)- Processes patient accounts in an assigned section (s) utilizing efficient methods and achieving optimum performance in accuracy and volume account management. Monitors assigned section (s} workflow, conduct quality audits and assists in the development of co-workers.
- Advises supervisor of internal progress and problems and of external problems with may hinder the completion of work within the section. Recommends solutions to problems.
- Assists with development of objectives and performance standards for sections{s) assigned. Implements aspects of new programs or services. Leads groups or task forces to accomplish special assignments.
- Reviews and suggests improvements in procedures and/or training guides.-
- Assesses, obtains, verifies, and documents patients insurance eligibility, benefits, and pre-certification requirements prior to services. (prior to , during and after services have been completed.)
- This includes pre-certification for infused medications.(all ordered services placed by all providers include integrated, aligned and non-integrated providers.)-
- Assists the patients in completing financial assistance applications.- Assists the patients in enrolling for any applicable patient assistance programs (PAPs).
- Collects all applicable patient signatures and financial documents as well as physician documents and submits applications on patients behalf. Tracks application process to ensure all documents were received and reviewed in a timely manner by assistance program.
- Registers patients on-line for copay card programs per program guidelines.-
- Works with drug manufacturers to get drug replacement in certain circumstances. Registers patients for programs which allow patients who meet criteria for drug replacement prior to initialing treatment as a fallback in case of denial.
- Works with pharmaceutical companies to appeal insurance carriers per their guidelines prior to drug replacement completion.- The Prior authorization representative arranges for peer to peer requests and order changes when an insurance company feels the clinical documentation does not meet requirements set by the insurance companies. Co-workers will contact the provider and obtain new order for services if needed in time for scheduled procedure.-
- Manages denials by researching root causes, collaborating with leadership regarding process improvements to prevent additional denials, including but not limited to staff training and development, work-flow enhancements, and identifying system errors.-
- Prior authorization representatives also assist in developing specialized education for the ministry on how to obtain authorizations not only for the centralized group but other clinics and departments as well. -
- Processes oncology(all specialty) patient accounts utilizing efficient methods and achieving optimum performance in accuracy.- Implements aspects of new programs or services.- Handles the most difficult patient complaints/program accounts.
- Models collaborative behavior with other staff members to accomplish work and departmental projects. Models positive and professional communication skills.
- Provides information and assistance to others regarding oncology (all specialty) billing and/or business office procedures and readily shares experience and expertise with others.- Coordinates and updates patient assistance program guidelines. - *
- **Prior Authorization representative uses standardized process to monitor and communicate in a timely manner with providers and the clinics when insurance companies need more information to prove medical necessity for requested tests as well as provide feedback as to why tests deny so that they are able to apply knowledge in the future as to what needs to be documented prior to ordering specific tests. -
- *** Prior Authorization representative routinely reviews procedural CPT changes that occurred
We Offer Great Benefits:
Day-one comprehensive health, vision and dental coverage, PTO, tuition reimbursement and employer-matched retirement funds are just a few of the great benefits offered to eligible co-workers, including those working 32 hours or more per pay period!
We're bringing to life a healing ministry through compassionate care.
At Mercy, our supportive community will be behind you every step of your day, especially the tough ones. You will have opportunities to pioneer new models of care and transform the health care experience through advanced technology and innovative procedures. We're expanding to help our communities grow. Join us and be a part of it all.
What Makes You a Good Match for Mercy?
Compassion and professionalism go hand-in-hand with us. Having a positive outlook and a strong sense of advocacy is in perfect step with our mission and vision. We're also collaborative and unafraid to do a little extra to deliver excellent care – that's just part of our commitment. If that sounds like a good fit for you, we encourage you to apply.
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