Smilow Fin Pre Denials Liaison

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

Under the direction of the Business Operations Manager, this position assures that patients at Waterford & Westerly Smilow get services needed related to oncology/hematology care plans administered at the Cancer Center, as well as supporting diagnostic imaging or other outpatient procedures ordered by the attending, and that the Hospital is paid for those procedures/services. This position will work collaboratively with Financial Clearance, providers and nursing teams to respond to up front denials for treatments and/or imaging procedures for clinical reviews and coordination of peer-to-peer reviews. This position will work as requested with Denial Analysts to reach resolution via appeals and provider rep contacts. This position will screen oncology patients for financial insecurities and provide out-of-pocket estimates. Assists with strategies to reduce future denials and helps facilitate operational changes to improve net revenue and reductions in denials

EEO/AA/Disability/Veteran

• 1. Responsible for verifying and ensuring any treatment performed at the Waterford or Westerly Cancer Center(s) or diagnostic imaging or outpatient procedure ordered by a Cancer Center attending provider has been authorized by the insurance company
• 2. Assures continued reimbursement through timely and effective referrals, authorizations and communication between the clinical staff and payors
• 3. Conducts investigations to determine root cause or initial denials, assesses coverage, coding and/or medical necessity compliance, conducts clinical documentation review, and/or by discussions with the applicable payor
• 4. Performs fast appeals by preparation of response to payers through appeal or medical necessity letters or clinical documentation to justify imaging, procedure or treatment regimens
• 5. Coordinates and facilitates peer-to-peer reviews
• 6. Conduct financial screening for oncology patients to identify underinsured or indigent patients
• 7. Provide patients with estimates for out-of-pocket costs, as requested
• 8. Recommends procedural changes to improve or to educate clinical and support staff on the authorization process
• 9. Acts as a liaison with Denial Analysts for appeals, collaborating with Physicians, clinical staff, governmental agencies, payors, and other Hospital departments as needed
• 10. Maintains current knowledge of regulatory and payor requirements to perform job responsibilities
• 11. Screens and refers applicable cases in need to financial counseling
• 12. Enters clear, concise notes concerning insurance authorization, appeal, denial status in Epic
• 13. Meets performance expectations for customer service, teamwork, resource utilization, and staff/self development as outlined in the performance review
• 14. Performs other duties as assigned or directed to ensure smooth operation of the department/unit
• 15. This position will not supervise anyone. However, the position does require a significant amount of collaboration and communication with insurance companies, physicians, oncology clinical staff, denial management and HIM

EDUCATION

Work requires organizational, analytical and communication skills generally acquired through the completion of a bachelor's degree in business, information technology, finance, or a related field. Additional years of experience above the minimum requirements may substitute for educational requirements on a one to one basis (i.e. one year of experience equals one year of education)

EXPERIENCE

Two (2) years of oncology related experience preferred. Previous prior authorization experience required. General knowledge of hospital billing and collection practices, third party reimbursement methodology with emphasis on governmental payors, strong analytical skills and excellent oral, written, and customer service communication skills are required. Knowledge of CPT and ICD-10 coding and medical terminology. Medical record review experience required. Proficient use of personal computers, Epic, Mosaiq, MS Word, Excel and Internet Explorer applications

LICENSURE

Specialized computer software (Epic, Mosaiq)

High School Diploma/GED, 2 years of oncology related experience, Previous prior authorization experience required, must have strong analytical skills, excellent written/oral and customer service communication skills, proficient use of personal computers, EPIC, Word, and Excel General knowledge in hospital billing and collections practices, third party reimbursement.