Insurance Utilization Reviewer Jobs in Madison, WI

Essential Duties and Responsibilities

• Ensures all scheduled visits are pre-registered and accounts are appropriately certified / authorized in advance of the service date.
• Initiates, obtains, and documents referrals/authorizations/pre-certifications in appropriate systems.
• Answers incoming external/internal telephone calls, determines purpose of calls and schedules appropriately or routes to physician practices or other departments as appropriate.
• Registers new and returning patients via multiline phone lines, and various Mercy systems/applications for visits within the Mercyhealth System ensuring that all required elements are gathered to ensure payment for the service provided.
• Initiates outbound calls to external providers, patients, and/or payers based on referrals entered into the system and schedules appropriately. Communicates with provider's office as needed.
• Ensures compliance with Access and Revenue Cycle related policies and procedures.
• Manages waitlists, rescheduling/cancellation of appointments as necessary.
• Completes accounts in assigned WQ's.
• Manages patient initiated scheduling requests through MyChart, Telehealth, or other self-scheduling applications.
• Maintains a high level of professionalism and provides a quality patient experience.
• Schedules appointments appropriately according to provider and clinic based protocols.
• Performs ancillary tasks by providing outreach to patients. Must have excellent customer service skills.
• Answers questions about organization and provides callers with address, directions and other information about the site that they are scheduled for.
• Able to articulate information in a manner that patients, guarantors, and family members understand.
• Ensures compliance with reporting related to demographics and federal and state requirements.
• Has in depth knowledge of community based, state or federal government programs to provide assistance to patients who have limited or no ability to pay for their health care needs. Screens patients and provides assistance with completion of applications, if necessary.
• Serves as a liaison to clinical staff by maintaining good communication regarding any problems and/or resolutions to patient issues or access concerns. Contacts insurance companies or employer groups via phone, web portals, electronic applications, or other appropriate means to determine eligibility and benefits for necessary services to obtain financial resolution and guarantee payment on account.
• Maintains current knowledge of payor payment provisions and regulations to ensure correct data is gathered and documented.
• Provides financial information to patients, which includes patient financial obligations, estimated costs of services, billing practices and establishing payment arrangements as necessary.
• Collects co-pays, deductible and other out of pocket expenses via phone and/or in person and ensures patients understand their financial obligation and arrange for payment at the time of visit.
• Must have a thorough understanding of patient payment options to be able to direct patients to appropriate resource for financial assistance programs. These programs may include Medicaid, Mercy Community Care and other community assistance as appropriate.
• Advises department leadership of possible postponement or deferral of any elective/non-emergent service which have not been approved prior to service date.
• Documents activity within appropriate EMR or patient accounting systems.
• Complies with Mercyhealth Cash Handling and Collection Policies.
• Demonstrates an understanding and follows patient confidentiality policies and all HIPAA Regulations.
• Performs other clerical duties as needed such as faxing, filing and photocopying.
• Subject matter expert with regards to assigned responsibilities.
• Provides training to new partners, as well as on an as-needed basis.
• Manages other duties as assigned.
• Completes pre-registration and ensures appropriate referrals are in place and authorized.
• Ensures compliance with Access and Revenue Cycle related policies and procedures.
• Reviews external orders/referrals to ensure authorization and compliance requirements are met.
• Assist with schedule utilization reports/documentation
• Participates in workgroups related to access/scheduling improvements.
• Notifies leadership of scheduling or access issues (time to next appt, provider cancellations, etc)
• OPAM schedules for all specialties and modalities across the system.
• OPAM Pre-Registration process is a different. As they are scheduling the patients and have them on the phone, they are reviewing their personal information and also checking on their insurance, is it in network, and additional verification. Triaging it a bit further as an example IF it is a worker's compensation and then follow additional information.
• Promoting digital access and patient engagement to get them to leverage the capabilities that exist. (example: EPIC)
• OPAM looks at the patient holistically, including current visit needs and then understanding additional needs of the patient and schedule them with another department.
• Broader view of schedules to ensure coordination occurs throughout the whole system rather than at one physical location.
• Ensure that Medical necessity is met.
• Utilization of waitlists for the system to ensure that we are accelerating patients accessing system.
• Focuses on schedule optimization by different area bringing in consistencies to services from a system perspective.
• Looking for throughput optimizations as they work with different areas to maximize scheduling efficiencies across the system.
• Needs the ability to understand multiple specialties and modalities and have the ability to support all of them.

Culture of Excellence Behavior Expectations

To perform the job successfully, an individual should demonstrate the following behavior expectations:
Quality - Follows policies and procedures; adapts to and manages changes in the environment; Demonstrates accuracy and thoroughness giving attention to details; Looks for ways to improve and promote quality; Applies feedback to improve performance; Manages time and prioritizes effectively to achieve organizational goals.
Service - Responds promptly to requests for service and assistance; Follows the Mercyhealth Critical Moments of service; Meets commitments; Abides by MH confidentiality and security agreement; Shows respect and sensitivity for cultural differences; and effectively communicates information to partners; Thinks system wide regarding processes and functions.
Partnering - Shows commitment to the Mission of Mercyhealth and Culture of Excellence through all words and actions; Exhibits objectivity and openness to other's views; Demonstrates a high level of participation and engagement in day-to-day work; Gives and welcomes feedback; Generates suggestions for improving work: Embraces teamwork, supports and encourages positive change while giving value to individuals.
Cost - Conserves organization resources; Understands fiscal responsibility; Works within approved budget; Develops and implements cost saving measures; contributes to profits and revenue.

Education and Experience

High school diploma or equivalent required.
Two years of customer service experience preferred.
Two years of healthcare registration, scheduling, or physicians' office experience required.

Certification and Licensure

Certification related to health care revenue cycle (Epic, AAHAM, NAHAM, HMFA, etc.) or an equivalently designated certification approved by management within 1 year of hire.

Skills and Abilities
Excellent oral communication skills/organizational skills
Ability to handle stress and problem solve
Computer experience preferred
Knowledge of EPIC desirable
Ability to multi-task
Able to work independently
Special Physical Demands

The Special Physical Demands are considered Essential Job Functions of the position with or without reasonable accommodations.
Prolonged sitting
Manual dexterity needed to operate telephone and keyboard.

Level of Supervision

This position has no supervisory responsibilities.

Supervises

N/A

PAY RANGE:

Mercyhealth is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identify, national origin, disability, or protected veteran status.

Mercyhealth offers competitive pay and a comprehensive benefits package including:

• Medical, Dental, Vision

• Life & Disability Insurance

• FSA/HSA Options

• Generous, accruing paid time off

• Paid Parental and caregiver leave

• Career advancement and educational opportunities

• Tuition and certification reimbursement

• Certification Reimbursement

• Well-being Programs

• Employee Discounts

• On-Demand Pay

• Financial Education

• Annual recognition/awards events

• Partner appreciation days

• Family entertainment/attractions discount

• Community service/improvement opportunities

Click here for more details regarding Mercyhealth Careers Benefit Information.

At Mercyhealth, we don't simply hire people, we empower employee-partners who are passionate about making lives better. As an integrated health system, we deliver exceptional, coordinated across seven hospitals, 85 primary and specialty clinics, and a team of over 7,500 professionals serving northern Illinois and southern Wisconsin.

Mercyhealth has been nationally recognized for our commitment to our people and culture, including:

• #1 in the nation on AARP's Best Employers for Workers Over 50

• One of Working Mother magazine's 100 Best Companies for Working Mothers

• A Top 50 Company and Top 10 Nonprofit for Executive Women