Payor Specialist

Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that’s served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It’s our passion.

PRIMARY PURPOSE

Responsible for communicating necessary clinical information to third party payors and others as necessary to ensure proper certification/approval of inpatient and post-discharge services. MINIMUM SPECIFICATIONS Education None.

Experience

- Must have two (2) years of experience in a hospital or physician business office including patient registration, interviewing, insurance verification/authorization, and/or managed care experience.

Skills or Special Abilities

- Must score 85% on pre-employment spelling test.

- Must be able to demonstrate a working knowledge of personal computers and other standard office equipment.

- Must have a working knowledge and medical terminology and medical software.

- Must have a thorough knowledge of third-party payors and understand managed care and insurance contractual arrangements.

- Must be detail oriented, possess basic mathematical skills, and have sharp analytical skills to resolve financial issues as they relate to multiple groups, including third party payors, physicians, and patients.

- Must demonstrate a positive demeanor, good verbal and written communication skills, and be professional in both appearance and approach.

- Must be able to handle potentially stressful situations and multiple tasks simultaneously.

- Must be able to communicate effectively with patients, families, government entities, insurance companies and Parkland staff.

Responsibilities

1. Serves as a lead resource with regard to the payor specialist function, answering questions and providing guidance to other staff members as needed.

2. Completes all documentation to appeal initial and concurrent insurance Adverse Determinations (denials) in collaboration with the Nurse Liaison and/or Senior Care Coordinators.

3. Maintains accurate information in EPIC system, including tracking, monitoring of LOS and denials/appeals, and ensuring accurate information.

4. Responsible for timely communicating preauthorization, notifications of admissions, initial and concurrent case management reviews with supporting clinical information and negotiating with third party payors to obtain payment authorization for appropriate level of care and length of stay.

5. Verifies and determines eligibility using different eligibility inquiry applications available to ensure account may be billed correctly.

6. Maintains database of payor interaction, payor grids, certification information, monitoring of LOS, denials/appeals, and other pertinent payor information ensuring accurate and current information. Proactively communicates any change in payor information and documents changes appropriately.

7. Identifies initial and concurrent denials by third party payors and notifies Nurse Liaison and/or Care Coordinator for timely intervention.

8. Generates reports regarding payor information on a daily, weekly or monthly basis, as required by supervisor and/or manager.

9. Stays abreast of the latest developments, advancements, and trends in medical insurance by attending seminars/workshops, reading professional journals, and actively participating in professional organizations and corporate compliance educational presentations. Integrates knowledge gained into current work practices.

10. Maintains knowledge of applicable rules, regulations, policies, laws, and guidelines that impact the third-party payor process. Adheres to internal controls for applicable state/federal laws, and the program requirements of accreditation agencies and federal, state, and private health plans. Seeks advice and guidance as necessary to ensure proper understanding.

11. Identifies ways to improve work processes and customer satisfaction. Makes recommendations to Supervisor, implements, and monitors results as appropriate in support of the overall goals of the department and Parkland.

12. Maintains a positive working relationship with contacts at all agencies, patients, insurance companies, government entities, clinical personnel, other Parkland staff and management, to promote teamwork, cooperation, and a positive public image for Parkland. Serves as a positive role model for staff and patients and demonstrates strong interpersonal skills. Accepts constructive criticism and integrates suggestions in effective ways.

Job Accountabilities 

Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of the department and Parkland.
Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and federal, state, and private health plans. Seeks advice and guidance as needed to ensure proper understanding.

Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status. As part of our commitment to our patients and employees’ wellness, Parkland Health is a tobacco and smoke-free campus.