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Payer Relations Specialist, 8am-4:30pm, 40hrs/wk, LincolnMadonna Rehabilitation Hospital • Lincoln, Nebraska, United States
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Payer Relations Specialist, 8am-4:30pm, 40hrs/wk, Lincoln

Madonna Rehabilitation Hospital
  • US
    Lincoln, Nebraska, United States
  • US
    Lincoln, Nebraska, United States
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**JOB DESCRIPTION** **Job Title: Payer Relations Specialist Job Code: 850005** Immediate Supervisor: Director of Admissions Status: Non-Exempt **JOB OVERVIEW** * Responsible for executing the payor authorization process for LTACH, IRF, and SNF programs. * Responsible for securing timely and accurate insurance authorizations, playing a critical role in supporting patient access, facilitating timely admissions, and ensuring reimbursement by working closely with clinical teams, payors, and admissions staff in a high volume environment. * Responsibilities include interdisciplinary collaboration, clinical documentation review, payer engagement, and proactive resolution of authorization barriers to optimize access and minimize delays in care transitions. * Ensures timely, efficient and cost-effective patient admissions to short-term rehabilitation programs. * Coordinates with payor sources and Admissions Coordinators for optimal program placement. * Contributes to establishing and maintaining strong positive working relationships with payors. * Communicates with inpatient teams, case managers and patient accounting to contribute to an efficient and coordinated program of care. * Responsible for identifying cases that could be a potential “financial risk” to Madonna Rehabilitation Hospital, Madonna Specialty Hospital, and Long Term Care at the time of referral/precert process. * The key element to this role is an appreciation of the CAS (Customer Access System). * Formulate an action plan and access all possible resources (internal and external) to eliminate that risk. * Communicate with all business sectors in order to make them aware of the potential risk and what action will be taken accordingly. * Works closely with the patient Access team. * Work will be performed in an ethical and legal manner following organizational policies, processes, protocols and procedures. * Responsible for quality service delivery and internal/external customer relations for Madonna as a whole, including upholding the mission and values for the department and facility.
**ESSENTIAL FUNCTIONS** 1. Process payor authorization and denials, involving and communicating with Admissions Team for completion. 2. Determines limitations of payor benefits, directing Admissions Team as needed prior to supporting admission (coordination of benefits, obtaining denials, OON process, P2P process). 3. Provide department assistance and coverage as assigned. 4. Submit appeals as needed. 5. Develop and maintain networking relationships with appropriate associates to gain knowledge, share information regarding rehabilitation services (e.g., payors, discharge planners, external case managers) and promote problem resolution and customer satisfaction. 6. Identify need for Director of Access & Reimbursement to negotiate single case agreements with insurance companies, workers compensation companies to ensure optimal reimbursement. 7. Coordinate with patient accounts to identify resolutions of non-payment related to authorization. 8. Assist in identification of payor issues related to currently held contracts and share information with appropriate personnel. 1. This may include identifying changes in network usage or identifying potential for establishing new contracts. 9. Stay up to date via payer bulletins, announcements, and website updates regarding authorization information in coordination with the Director of Access and Reimbursement. 10. Train new staff, as appropriate, in obtaining sufficient information when determining benefit eligibility and trends which may impact obtaining preadmission assessments, and in communication of trends which referral sources may find pertinent. 11. Follow instruction from supervisor to perform other functions as assigned in order to achieve the goals within the department. 12. Clinical documentation coordination with the Admissions team. 13. Maintain a clean, organized and safe environment. 14. Handles and operates all necessary equipment and performs required duties according to established safety standards to maintain compliance with regulations and prevent injury. 15. Employees will work hybrid/remote. When working remotely, employees must have a dedicated, secure, and quiet workspace free from distractions, with reliable internet and a setup conducive to focused work. 16. Must be able to operate copier, telephone, fax machine and have proficient computer skills, including e-mail, word processing, presentation, and spreadsheet functions.
**PHYSICAL DEMANDS AND ENVIRONMENTAL CONDITIONS** Light work, requires walking and standing to a significant degree. Ordinary speaking and hearing skills. Normal vision to read written documents. Primarily indoor work, with the exception of travel. Mobility required for travel to scheduled events or meetings as needed. Able to work independently, but willing to reach out for assistance as needed. **QUALIFICATIONS** (Education/training and/or Experience) * Associates Degree in allied health and one year relevant work experience required. * Bachelor’s degree and case management experience preferred. * Additional relevant work experience as determined by Madonna may be considered in lieu of formal post high school education. * In-depth knowledge of clinical terminology and the ability to complete clinical assessments required. * Requires extensive knowledge of insurance types (e.g., HMO, PPO, POS); insurance terminology (e.g., preferred provider network, coordination of benefits); insurance professionals (e.g., case managers, utilization review coordinators, medical reviewers, claims adjudicators, provider liaisons); and insurance payment provisions (e.g., per diems, discount off charges, case rates, carve outs). * Also requires working knowledge of Medicare, Medicaid and Workers Compensation provisions and how these programs coordinate with commercial insurance coverage. * Must be able to process complex information quickly to negotiate optimal program placement for patients while on the telephone with insurance company representatives. * Must possess excellent communication and negotiation skills, both written and verbal, and have demonstrated ability to work independently with strong organizational and time management skills to prioritize responsibilities. * Requires computer experience using Microsoft Word, Excel and Power Point. Background checks are conducted. When specific authorization forms are requested so that full background and history can be obtained, employees/applicants must sign the form(s) requested.
  • Lincoln, Nebraska, United States

Sprachkenntnisse

  • English
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