WVU Medicine

Academic health system

Manager Enterprise Authorization Services

Clinical Support & Patient AdministrationConfirmed live in the last 24 hours

Full-timeRemote in USANo salary listedRemote

About the Job

Requirements

A high school diploma or equivalent is required.
Five years of experience in healthcare accounts receivable management, billing, and collections are required.
Two years of supervisory experience are required.
Considerable knowledge of computers and the use, manipulation, and application of data in support of administrative functions is required.
Knowledge of Medicare, Medicaid, and other regulatory requirements is required.
Knowledge of UB-04, itemized bills, insurance plans, grievance procedures, and utilization management processes is required.
Knowledge of managed care, inpatient and outpatient care, utilization management, and InterQual criteria is required.
Knowledge of patient billing operations is required.
Knowledge of medical terminology and the ability to interpret information in the medical record are required.
Knowledge of CPT, ICD-9/10, and DRGs is required.
Previous experience in an administrative or supervisory role is required.
Ability to hold others accountable for performance related to revenue lost through denials is required.

Responsibilities

Serve as the primary contact for coordinating and controlling activities related to obtaining insurance prior authorization, and research and analyze denied services to ensure processes and workflows are created and implemented to minimize payment denials.
Manage a team of authorization specialists responsible for insurance verification and prior authorization of assigned services.
Interview, hire, train, develop, direct work processes, manage performance, manage time and attendance, and recognize and reward employees.
Communicate effectively with hospital personnel.
Provide timely communication to Departmental Directors and Clinic Administrators regarding revenue risks within their departments, and participate in process design to mitigate identified risks.
Review and manage authorization productivity and timeliness, develop and implement action plans as appropriate, and report delays to Department Leadership.
Stay current on regulatory billing updates, regulatory requirements, and organizational compliance policies to avoid audits, appeals, and denials.
Maintain staffing levels and reassign work according to organizational priorities when necessary.
Manage and regularly audit Authorization staff work to ensure quality and productivity, and monitor staff compliance with authorization and treatment-plan submission timelines.
Monitor data trends relating to insurance authorization and reimbursement and report findings to the Director.
Identify process improvement opportunities and develop, implement, monitor, and revise action plans.
Propose opportunities to improve current technology to enhance performance and productivity.
Maintain working knowledge of authorization requirements for all payors and state and federal regulatory guidelines for outpatient service coverage and authorization.
Oversee precertification requirements for assigned services and create and implement workflows and processes to improve system reimbursement.
Use denial-management metrics to monitor progress on denials and identify process initiatives.
Work with hospital billing, professional billing, Outpatient Registration, and Revenue Cycle to monitor insurance authorization and reimbursement trends, handle complex denials, and lead multi-departmental efforts to resolve authorization barriers and prevent payment denials.
Manage the functions of assigned hospitals to ensure timely review and facilitate front-end appeals through peer-to-peer processes.
Attend relevant meetings inside and outside the hospital to represent pre-authorization services.
Analyze new services and provide guidance regarding pre-authorization and denial reduction.

Desired Qualifications

A bachelor's degree in Finance, Business Administration, or a related field is preferred.
Certified Healthcare Financial Professional (CHFP) certification from the Healthcare Financial Management Association (HFMA) is preferred.
Knowledge of the EPIC system is preferred.

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Serves as the primary contact for coordinating and controlling all activities related to obtaining insurance prior authorization, and researching and analyzing denied services to ensure processes and workflows are created and implemented to minimize payment denials. Manages a team of authorization specialists responsible for insurance verification and the prior authorization of various assigned services.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. High School Diploma or Equivalent.

EXPERIENCE:

1. Five (5) years’ experience healthcare accounts receivables management, billing and collections.

2. Two (2) years of supervisory experience.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s degree in Finance, Business Administration or related field.

2. Certified Healthcare Financial Professional (CHFP) with the Hospital Financial Management Association (HFMA).

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Responsible for all aspects of managing and leading a team including: interviewing, hiring, training, developing, directing work processes, managing performance, managing time and attendance, and recognizing and rewarding employees.

2. Demonstrates ability to communicate effectively with hospital personnel.

3. Provides direct and timely communication to Departmental Directors and Clinic Administrators regarding revenue risks within their departments. Participates in process design that will mitigate identified risks.

4. Promotes collegiality, recognizes responsibilities and performs them willingly with positive impact on patients, coworkers, and external providers.

5. Reviews and manages productivity and timeliness of authorization and Develops/implements action plans appropriately. Reports delays to Department Leadership.

6. Stays abreast of updates and changes to regulatory billing updates, regulatory requirements and organizational compliance policies to avoid audits and appeals/denials

7. Proactively works to maintain staffing levels, and reassigns work according to organizational priorities when necessary.

8. Manages and regularly audits the work of all Authorization staff to ensure high quality and productivity. Monitor and track staff compliance regarding timeliness of obtaining authorizations and treatment plan submission to ensure ongoing attention to timely processing accounts

9. Monitors data trends relating to insurance authorization and reimbursement and reports on such to Director

10. Identifies process improvement opportunities and develops, implements, monitors and revises action plans.

11. Anticipates and proposes opportunities to improve current technology to enhance performance and productivity.

12. Maintains a good working knowledge of authorization requirements for all payors and state/federal regulatory guidelines for coverage and authorization of outpatient services

13. Oversees pre-certification requirements for assigned services to create and implement necessary workflows and processes to improve system reimbursement.

14. Uses data analysis related to Denial Management metrics to monitor progress on denial and looks for process initiatives.

15. Works closely with hospital billing, professional billing, Outpatient Registration and Revenue Cycle in monitoring data trends relating to insurance authorization and reimbursement and handles complex denials. Responsible for leading multi-departmental efforts to resolve any barriers to completing authorizations and avoiding denials of payment.

16. Manages the functions of the assigned hospitals to ensure timely review, and facilitates the front end appeals through peer to peer.

17. Attends relevant meetings in and outside the hospital to represent pre-authorization services.

18. Analyzes new services for guidance regarding pre-authorization and denial reduction.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

SKILLS AND ABILITIES:

1. Considerable knowledge of computers and the use/manipulation/application of data in support of administrative functions.

2. Knowledge of EPIC system is preferred.

3. Knowledge of Medicare, Medicaid and other regulatory requirements.

4. Knowledge of UB-04, itemized bills, insurance plans (i.e. Commercial Medicare, Medicaid, HMO, PPO, etc.) grievance procedures and utilization management processes required.

5. Knowledge of managed care, inpatient and outpatient care, utilization management, Interqual criteria.

6. Knowledge of the operations of patient billing is required.

7. Knowledge of medical terminology and the ability to interpret information in the medical record is required.

8. Knowledge of CPT, ICD9/10, and DRGs.

9. Previous experience in administrative or supervisory role.

10. Effective organizational skills, attention to detail, ability to take initiative and excellent follow through a must.

11. Ability to function as a team player and support of colleagues and staff is essential.

12. Ability to hold others accountable to performance related to lost revenue due to denials.

Additional Job Description:

Scheduled Weekly Hours:

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

SYSTEM West Virginia University Health System

Cost Center:

536 SYSTEM Hospital Authorization Unit

About the Company

WVU Medicine

Academic health system

WVUMedicine is an academic health system serving West Virginia and the surrounding region. The system operates hospitals, clinics, specialty programs, emergency care, research, and medical education through an integrated network. It serves patients, families, referring clinicians, students, researchers, and regional communities. Its operating model centers on clinical care, hospital operations, ambulatory services, education, research, and shared system support. Teams work across nursing, physicians, allied health, research, technology, facilities, administration, and patient services. Work depends on coordination among clinical, operational, technical, and support teams across its care settings and communities.

Company size: Not listed
Company stage: Not listed
Total funding: Not listed
Headquarters: Not listed
Founded: Not listed

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