"Clinical Finance Case Management Specialist 2"

Scope of Position

This position ensures the coordination of the insurance verification and prior authorization process for outpatient medications. This process includes assisting in defining pharmacy co-pay information, benefit limitations and coverage, important to both patient and physician planning as well as ensures the appropriate information for successful billing.

Position Summary

Responsibilities include understanding and verifying benefits and obtaining prior authorization for outpatient medications. In addition, the advocate will at times contact patients/families in order to ascertain additional demographic, financial, and insurance information essential to the authorization processes while also informing patients of medication co-pays. Must be able to utilize the electronic medical record system to obtain pertinent medical information for prior authorization process. Will solve routine customer problems. Will communicate regularly with the physicians, physician offices and payers when limitations, restrictions, documentation requirements and etc. are needed for prior authorizations to take place. Must be able to evaluate complex issues and understand escalation procedures. Displays the highest level of customer service, attentiveness and consideration possible in all cases. Uses multiple system applications and customer service skills to facilitate optimal experience for the patient and successful first time billing for the hospital system.

Minimum Qualifications

For Hire:

Bachelor degree and experience in healthcare setting or physicians practice required. Registered Nurse preferred. Experience in interpreting insurance benefit information and completing prior authorization process preferred. Knowledge of medical terminology preferred. Experience with internet and internet navigational tools is very helpful. Excellent interpersonal skills especially communication, ability to work effectively with team desired. Must be highly organized, detail oriented, and able to manage multiple projects at a time. Must complete PTCB certification within 365 days of hire, unless current PTCB certificate is in place upon hire.

On going:

PTCB certification must be maintained for continued employment. Demonstrates competence in daily functions, interpersonal and cognitive skills required to meet essential job functions. Remain current with all departmental computer software essential. Attends medical center and departmental in-services, educational forums and meetings as required.