Payor Specialist Full-time Days Hybrid

The Payor Specialist reflects the mission vision and values of NM adheres to the organizations Code of Ethics and Corporate Compliance Program and complies with all relevant policies procedures guidelines and all other regulatory and accreditation standards.

The Payor Specialist supports the Clinical Documentation and Quality Utilization team to efficiently communicate with payors and ensure timely initial stay authorization and continued stay authorizations for acute care inpatients. The Payor Specialist collaborates with the Quality Utilization Specialist in order to effectively communicate accurate clinical information to payors to obtain preauthorization precertification and continued stay authorization for appropriate levels of care and length of stay.

Responsibilities:

• Assists in the communication of clinical information provided by the Quality Utilization Specialist with all payors using a variety of methods including faxing payor web entry and verbal communication.
• Obtains timely payor determinations regarding certification of hospital stay and accurately records and conveys the determination to the Quality Utilization Specialist.
• Tracks and assures compliance with payor requests for information and communicates payor requests to appropriate Quality Utilization Specialist as needed.
• Communicates with and coordinates Onsite Payor Review activities to assure timely certification determinations.
• Documents and communicates denial and peer review information to the Quality Utilization Specialists and the Lead Quality Utilization Specialists. 
• Communicates patient outofnetwork status and contact information to the Quality Utilization Specialists.
• Ensures inpatient precertification is obtained through communications with registration staff in the Patient Access Unit.
• Provides feedback to utilization staff and management as needed regarding payor guidelines issues and determinations discovered during communication with payors.
• Ensures payor and customer satisfaction by utilizing effective communication and interpersonal skills.
• Provides entry tracking and trending of Quality and Documentation data and outcomes as directed.
• Participates in Performance Improvement initiatives and performs other Quality and Documentationrelated functions as directed.
• Maintains uptodate payor contact list.
• Mails out appeals initiated by the Lead Quality Utilization Specialists..
• Distributes and processes payor mail including but not limited to authorization and denial letters.
• Upholds the Northwestern Memorial Hospital policy on patient confidentiality.
• Assists with data preparation and the creation of presentation materials as needed for the Quality and Documentation Team.
• Exhibits Patients First behavior to patients visitors physicians and employees. Ensures that the processes on the offshift holidays and weekends are patient driven and efficient. Responsible for identifying quality improvement opportunities of shift operations. Tracks routine measures that are identified as Quality Indicators.

Qualifications :

Required:

• Associates degree OR high school diploma/GED equivalent with minimum 4 years experience in a healthcare setting
• Minimum 1 year of relevant work experience  
• Computer and database management skills to efficiently and effectively manage Clinical Quality and Documentation Department electronic systems including Allscripts Epic etc 
• Interpersonal and communication skills to effectively deal with a variety of people including physicians hospital leaders nursing staff patients and family members.

Preferred:

• Bachelors degree
• 35 years of healthcare experience
• Conversant with medical terminology.
• Expertise and knowledge of thirdparty payor Medicare/Medicaid guidelines

Additional Information :

Northwestern Medicine is an affirmative action/equal opportunity employer and does not discriminate in hiring or employment on the basis of age sex race color religion national origin gender identity veteran status disability sexual orientation or any other protected status.

Remote Work :

No

Employment Type :

Fulltime