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Payor Specialist, Full-time, Days

Chicago, Illinois Job REQID 8912 Job Function Administrative Support Shift Day Job (1st) Apply Now

At Northwestern Medicine, every patient interaction makes a difference in cultivating a positive workplace. This patient-first approach is what sets us apart as a leader in the healthcare industry. As an integral part of our team, you'll have the opportunity to join our quest for better healthcare, no matter where you work within the Northwestern Medicine system. At Northwestern Medicine, we pride ourselves on providing competitive benefits: from tuition reimbursement and loan forgiveness to 401(k) matching and lifecycle benefits, we take care of our employees. Ready to join our quest for better?

Description

ESSENTIAL FUNCTIONS:

  • 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 out-of-network status and contact information to the Quality Utilization Specialists.
  • Ensures inpatient pre-certification 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 Documentation-related functions, as directed.
  • Maintains up-to-date 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.
  • AA/EOE.

Qualifications

Required:

  • High school diploma with at least five years healthcare experience or Associates Degree in healthcare-related field with three to four years experience.
  • Conversant with medical terminology.
  • Expertise and knowledge of third-party payor, Medicare/Medicaid guidelines.
  • Computer and data base management skills to efficiently and effectively manage Clinical Quality and Documentation Department electronic systems, including the Extended Care Information Network system software (ECIN).
  • Interpersonal and communication skills to effectively deal with a variety of people, including physicians, hospital leaders, nursing staff, patients, and family members.

Equal Opportunity

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.
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