Children's National Medical Center
Payor Reimbursement Analyst
Children's National Medical Center, Silver Spring, Maryland, United States, 20900
Job Title:
Payor Reimbursement Analyst (240001YP)
Description:
The Payor Reimbursement Analyst will support the financial sustainability of the organization through timely, accurate, and thorough research of reimbursement issues related to Medicaid and Commercial payors. Responsible for tracking, trending, and reconciling data and reporting to the Revenue Cycle. Develop and maintain collaborative relationships with payors, Access, Clinics, Managed Care, Business Operations, Leadership, and Legal departments.
Qualifications:
Minimum Education:BSN (Required)Master's Degree (Preferred)
Minimum Work Experience:5 years Experience with 3 years of Utilization Review. (Required)
Required Skills/Knowledge:Ability to critically think and apply logic and reasoning to a dynamically changing healthcare environment. Requires superior verbal communication skills and a service excellence approach with internal and external stakeholders. Must have strong business writing skills. Proficient at keyboarding and facile with Microsoft Office Excel, Access, and PowerPoint.
Functional Accountabilities:
Authorizations & Denials:
Provide timely, comprehensive, and accurate review of authorizations/denials to determine appropriate course of action.
Provide clear direction to others to resolve authorization/denial issues.
Provide timely appeals based on standardized criteria (Interqual and MCG) and follow appropriate escalation processes.
Monitor payor response to appeals to ensure timely claim payment or write-off.
Function as a subject matter expert for CRM, Revenue Cycle, and the organization.
Data Management:
Tracks, trends, and analyzes all authorization issues and denials by payor utilizing relevant software.
Report data on a weekly, monthly, quarterly, or yearly basis as requested to report out to Revenue Cycle.
Propose process improvements for various stakeholders based on data analysis to mitigate future denials.
Communication/Collaboration:
Communicate and collaborate with internal and external partners to optimize reimbursement.
Actively participate in payor meetings to contribute to discussions of Authorization and Denials data and trends.
Develop cogent, comprehensive appeals utilizing standardized criteria or evidence.
Education:
Contribute to the education of CRM, Medical, and other hospital staff about authorization and denials.
Based on authorization and denial patterns, develop and implement an educational plan for various staff roles.
Organizational Accountabilities:
Partner in the mission and uphold the core principles of the organization.
Committed to diversity and recognizes the value of cultural and ethnic differences.
Demonstrate personal and professional integrity.
Maintain confidentiality at all times.
Customer Service:
Anticipate and respond to customer needs; follow up until needs are met.
Teamwork/Communication:
Demonstrate collaborative and respectful behavior.
Partner with all team members to achieve goals.
Receptive to others’ ideas and opinions.
Performance Improvement/Problem-solving:
Contribute to a positive work environment.
Demonstrate flexibility and willingness to change.
Identify opportunities to improve clinical and administrative processes.
Make appropriate decisions, using sound judgment.
Cost Management/Financial Responsibility:
Use resources efficiently.
Search for less costly ways of doing things.
Safety:
Speak up when team members exhibit unsafe behavior or performance.
Continuously validate and verify information needed for decision-making or documentation.
Stop in the face of uncertainty and take time to resolve the situation.
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Payor Reimbursement Analyst (240001YP)
Description:
The Payor Reimbursement Analyst will support the financial sustainability of the organization through timely, accurate, and thorough research of reimbursement issues related to Medicaid and Commercial payors. Responsible for tracking, trending, and reconciling data and reporting to the Revenue Cycle. Develop and maintain collaborative relationships with payors, Access, Clinics, Managed Care, Business Operations, Leadership, and Legal departments.
Qualifications:
Minimum Education:BSN (Required)Master's Degree (Preferred)
Minimum Work Experience:5 years Experience with 3 years of Utilization Review. (Required)
Required Skills/Knowledge:Ability to critically think and apply logic and reasoning to a dynamically changing healthcare environment. Requires superior verbal communication skills and a service excellence approach with internal and external stakeholders. Must have strong business writing skills. Proficient at keyboarding and facile with Microsoft Office Excel, Access, and PowerPoint.
Functional Accountabilities:
Authorizations & Denials:
Provide timely, comprehensive, and accurate review of authorizations/denials to determine appropriate course of action.
Provide clear direction to others to resolve authorization/denial issues.
Provide timely appeals based on standardized criteria (Interqual and MCG) and follow appropriate escalation processes.
Monitor payor response to appeals to ensure timely claim payment or write-off.
Function as a subject matter expert for CRM, Revenue Cycle, and the organization.
Data Management:
Tracks, trends, and analyzes all authorization issues and denials by payor utilizing relevant software.
Report data on a weekly, monthly, quarterly, or yearly basis as requested to report out to Revenue Cycle.
Propose process improvements for various stakeholders based on data analysis to mitigate future denials.
Communication/Collaboration:
Communicate and collaborate with internal and external partners to optimize reimbursement.
Actively participate in payor meetings to contribute to discussions of Authorization and Denials data and trends.
Develop cogent, comprehensive appeals utilizing standardized criteria or evidence.
Education:
Contribute to the education of CRM, Medical, and other hospital staff about authorization and denials.
Based on authorization and denial patterns, develop and implement an educational plan for various staff roles.
Organizational Accountabilities:
Partner in the mission and uphold the core principles of the organization.
Committed to diversity and recognizes the value of cultural and ethnic differences.
Demonstrate personal and professional integrity.
Maintain confidentiality at all times.
Customer Service:
Anticipate and respond to customer needs; follow up until needs are met.
Teamwork/Communication:
Demonstrate collaborative and respectful behavior.
Partner with all team members to achieve goals.
Receptive to others’ ideas and opinions.
Performance Improvement/Problem-solving:
Contribute to a positive work environment.
Demonstrate flexibility and willingness to change.
Identify opportunities to improve clinical and administrative processes.
Make appropriate decisions, using sound judgment.
Cost Management/Financial Responsibility:
Use resources efficiently.
Search for less costly ways of doing things.
Safety:
Speak up when team members exhibit unsafe behavior or performance.
Continuously validate and verify information needed for decision-making or documentation.
Stop in the face of uncertainty and take time to resolve the situation.
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