TCHP Authorization Assistant - Rheumatology - Full Time - Days

Job Description

This position will be scheduled approximately 40 hours per week located at our Rheumatology Arthritis Care Clinics in Montgomery, Milford and Norwood.

Responsible for conducting and completing necessary third party prior authorization requests to ensure optimal reimbursement for medications. Performs specific functions requiring specialized education (Coding), knowledge of NCCN and LCD/NCD guidelines for drug therapy indications payable by insurers.

Responsibilities

Review and evaluate procedures to assure the appropriateness and medical necessity of medication use based on LCD/NCD/NCCN guidelines. Obtain prior authorization for administration from intermediaries including HMO's, insurance companies and review organizations. Ensure completion of activities that maximize revenue capture for all medications. Maintain knowledge of current HMO/PPO/Medicaid/Medicare/commercial insurance regulations and requirements. Requires working knowledge of insurance plans The Christ Hospital network participates with. Determines all insurance coverage's as primary, secondary, tertiary, etc.

Initiates on-line verification of third party insurance to verify patient coverage. Evaluates and prepares chart documentation to establish that medical necessity guidelines have been met. Prepares and completes documentation that establishes Medicare compliance, such as Advance Beneficiary Notice (ABN). Documents appropriate data.

Facilitate adherence to Christ Hospital's internal prior authorization requirements by working with the patient care team and within medication guidelines. Capture revenue for medications by completing third party (external) medication authorizations. Understand, anticipate, and respond to complex questions from third party payers. When necessary, proactively contact third parties and initiate communication to ensure appropriate future payment.

Facilitate adherence to Medicare requirements including knowledge of Medicare Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs) and Advanced Beneficiary Notice (ABN) processes. When ABN is required, prepare and price ABNs and provide to clinic staff/providers and facilitate clinic medication ABN process. Assure patient has received communication from clinic staff/provider regarding ABN and assure patient signature is obtained prior to initiation of medication therapy. Communicate directly with patients regarding ABN process as needed.

Determine organizations participation in insurance contracts. Maintains knowledge of current HMO/PPO/Medicaid/Medicare/Commercial Insurance regulations and requirements. Screens and completes all required documentation and prioritizes all insurance coverage's as primary, secondary, tertiary. Prescreen payment sources to identify problematic payers or payers who do not recognize The Christ Hospital Physicians as the preferred place of care. Collaborate with clinic staff and providers to refer the patient to their appropriate place of care.

Interact with medical and professional staff on a case-by-case basis to obtain appropriate clinical documentation to ensure accurate indications in the patient's medical record before completion of third party prior authorizations. Utilize resources such as email and telephone to communication pertinent patient information to staff and nurse managers. Develop an effective, supportive working relationship with the staff in the clinic, front desk, billing and financial advocates. Problem solve to meet patient care needs; identify and produce creative solutions to problems identified via the prior authorization process. Effectively communicate unsupported medical necessity to physician and confidentiality of all patient related information.

Qualifications

KNOWLEDGE AND SKILLS:

EDUCATION: High School Diploma, Associates Degree preferred or equivalent combination education and experience.

YEARS OF EXPERIENCE: One to three years of experience in obtaining authorizations for medical services.

REQUIRED SKILLS AND KNOWLEDGE:

• Analytical skills required to make decisions based on the facility and clinical situation at hand.

• Computer Literacy - use of multiple systems Onco and Epic

Ability to use Internet Access and utilize third party payor systems for eligibility and verification.

• Knowledge of health insurance coverage, requirements.

• Excellent communication, problem solving skills, and ability to deal with customers who are often adversarial. Ability to be flexible, organized and function well in stressful situations. Ability to interact independently to resolve Customer Service issues.

• Typing (minimum of 35 words per minute).

• Must understand medical terminology

About Us

For more than 130 years, The Christ Hospital been the beacon for exceptional healthcare in the Greater Cincinnati community. We're industry pioneers, always pushing the boundaries and reimagining the future of healthcare.



Our culture promotes collaboration, diversity and innovation. Together, as a team, we work tirelessly to enhance healthcare quality, accessibility and safety.