Hybrid Insurance Verification-Utilization Specialist bei Carolina Therapeutic Services

Description

Utilization management’s primary function is to conduct utilization reviews of initial authorizations and concurrent authorizations for new and existing persons referred, requesting or actively receiving services.  The SAU Department reviews authorizations for all MCOs for NC and services. The SAU Department conducts perspective, concurrent, and retrospective reviews for authorization of MCOs/services for individuals, conducts reviews using clinical information submitted by Program Managers, adds authorizations to trackers, enters authorizations and client information into system, verifies insurance, and informs Program managers of approval or denials.

Insurance Verification

Overall responsibility for ensuring that patient health care benefits cover required procedures. This individual contacts a patient’s insurance company to verify coverage levels and works with individuals to educate them on their benefits information. Additionally, this individual works to meet State and Federal Regulatory guidelines and comply with agency policies and procedures. Ensures the duties are completed in a timely and proper manner. 

Responsibilities:  

PRN MA as needed 

Insurance Verification Specialist is responsible for obtaining verification of patient payer benefits and eligibility. Includes Private Insurance, Veteran’s Association, Medicare/Medicaid

? Ongoing written and verbal communication with case staff regarding authorization, re-authorization, and retro-authorization of visits 

? Provide accurate documentation of conversations regarding patients 

? Working knowledge of specific contracts between the agency and various payers

? Ensures that cases are effectively managed according to utilization and authorization, as defined by payer. This function includes documentation and ongoing maintenance of authorization and reauthorization

? Acting as a resource to patients and communicating as appropriate with other family members involved in patient care insurance coverage 

? Utilizes sound customer service principles in relating to patients by negotiating effectively, resolving conflicts, seeking assistance as appropriate management, and responding as appropriate and communicating the agency’s spectrum of care ? Scan insurance documents as needed 

? Works under the direction of “Billing Manager”, assist with duties as directed ? Process new intakes/referrals as requested ? Electronic and paper filing, including but not limited to patient and insurance company correspondence

? Answer incoming calls as needed

? Other duties as assigned duties

Utilization

· Requests for support documentation from program managers as needed 

· Participant in state and local audits 

· Assist others with issues in EMR systems

· Submit Initial and Concurrent Authorizations to MCOs for assigned contract areas

· Verify client insurance coverage for authorization submission

· Coordinate with MCO to resolve documents issues submitted for authorizations??

· Gather all needed forms prior to submitting to MCO.

· Review accuracy and completion of all needed forms (dates, names, recommended services, signatures, etc.)

· Communicate with program managers when authorizations are completed, and clients are ready to be billed.

· Update all client’s trackers for completion of needed documents, authorizations, and their due dates. 

· Add client demographics to EMR systems (update as needed)

· Identify authorizations and add authorization for Assessments, OPT, crisis (update as needed)

· Print and provide audit personal authorization for client’s charts.

· Identify if Assessment have been billed and billed on correct dates. Will contact Lead Therapist if any issues.

· Have weekly meetings with different service departments and verify billing dates are within range for service

· Requests support documentation from program?managers, Case Works, therapist as needed?

· Report critical concerns and problems to?Supervisor?in a timely manner and actively seek Supervisor’s?input and assistance to 

  resolve the concern.??

Professional Responsibilities: 

· Abide by and implement all the policies, procedures, regulations, and standards that govern the agency.  

· Represent Carolina Therapeutic Services Inc. professionally in the community with all other agencies (i.e. schools, court system, 

  mental health, department of social services, etc.) 

· Maintains strict confidentiality according to all Federal and State guidelines and requirements. 

· Exemplifies personal and professional conduct. 

· Upholds the Professional Code of Ethics. 

· Maintains a cooperative relationship with employees, medical staff and others. 

· Demonstrates tact, courtesy, and a positive approach to communication and interaction with other employees, visitors, physicians, 

· Responsible for personal development to ensure current knowledge in the profession. 

· Responsible for maintaining a safe, clean and drug free environment. 

Communication: 

· Work with a team approach with other employees to ensure efficacy of care for ALL Consumers. 

· Report critical concerns and problems to Supervisor in a timely manner and actively seek Supervisor’s input and assistance to 

  resolve the concern.  

· Follow chain of command when encountering problems or other areas of need and correct problems requested. 

· Solicit and cooperate with assistance of all support staff. 

· Actively participate in an appropriate manner with the decision-making process as “pro-active” team members and cooperate with

  team’s decision, whether programmatic or clinical.  

· Provide coverage on-site or as assigned by the needs of the agency.  

· Attend staff meetings, planned in-service training and any other regular or assigned meetings. 

· Responsible for any equipment assigned to perform duties.  

· Facilitate flow of information, particularly as it affects the delivery of services to consumers. 

· Manage transportation, scheduling, staffing and service delivery concerns and cooperate with treatment team members in 

  resolving concerns.  

· Perform other required job duties that the supervisor and/or director require to maintain continuity of care for consumers and

  profitability for the agency. 

Requirements

Qualifications and Education Requirements: 

· Must be at least 18 years of age, be able to read, write and affect both written and verbal communication

· Understand and follow directions. 

· Possess no substantiated findings of abuse or neglect listed on Health Care Registry, and no criminal convictions.  

· ICD- 10 -3 years of experience preferred

· Medical Billing 5 years of experience preferred

· Strong computer skills including MS Excel and proficiency working with spreadsheets

· Great Organizational and communication skills

· Self-motivated individual who can work independently with minimal direction

· Experience working with EMR systems

· Problem solving skills and ability to deal effectively and efficiently with a high volume of denied and incorrectly paid claims

· Knowledgeable in invoicing, deductibles, and copays

· Understanding of patient eligibility

· Experience working with Medicaid, Medicare, and all commercial insurances

· Knowledge of medical and behavioral health terminology