Payer Services Specialist

Responsibilities

• Perform tasks assigned in areas of centralized eligibility, prior authorization intake, or recertification as delegated or assigned by Payer Services Team Lead or Director.
• Provide education on authorization, recertification, and benefit eligibility to campuses.
• Research and assist the BOM and revenue cycle team with denial research as it pertains to eligibility or authorizations denials.
• Assist in identifying areas of opportunity and collaborate to troubleshoot and rectify problems within the authorization or eligibility process.
• Validate and verify patient’s active insurance benefits, demographics, prior authorization requirements, network status, and financial information for the purpose of guaranteeing reimbursement for services rendered and to minimize collection issues and/or bad debt expense.
• Initiate on-line verifications and/or make phone contact with Insurance Carriers and Plan Administrators to validate patient’s benefits for primary and secondary coverage.
• Responsible for completing the Preadmission Financial Verification prior to admission in a timely manner.
• Determine if override requirement is necessary based upon company set thresholds and campus specific contract details.
• Provide campus team support explaining residents’ benefits and requirements.
• Verify and understand various insurance company benefits for Skilled Nursing and Outpatient Therapy services.
• Determine patient financial responsibility.
• Document complete and accurate data relating to all necessary eligibility, benefits, and precertification information for the appropriate Matrix Care database fields after admission or services rendered.
• Maintain a thorough understanding of all major insurance plans and network/contracted provider verification requirements.
• Ensure billing information and authorization requirements are communicated to the campus and prior authorization intake so that MatrixCare is set up correctly and claims can be billed accurately.
• Negotiate Single Case Agreements with managed care and other insurance carriers for reimbursement.
• Assist in researching escalated issues from payers, case managers, revenue cycle team or campuses in a timely and effective manner and provide audit of process to identify system or process failures.

Requirements

• High School diploma or equivalent.
• Bachelor’s degree or higher in accounting or business or related field preferred.
• Minimum of five (5) years healthcare insurance experience in a healthcare, senior living industry, long-term care environment preferred, healthcare billing or managed care organization.