Principal Admitting Worker - CCS

The California Children's Services (CCS) Authorization Representative is individually accountable for securing treatment authorizations for the CCS patient population that includes inpatient admissions and ancillary outpatient services. The CCS Unit is responsible for meeting organizational financial targets of approximately $22 million each week for CCS DNB (Discharged Not Billed) patient accounts. Collectively, the CCS Authorization Representative team contributes to timely and appropriate patient access and service for CCS covered conditions. The scope of work that the Authorization Representative is responsible for requires ongoing account analysis, consistent communication of technical medical language and unique patient accounts and CCS coverage guidelines and billing knowledge.

The primary responsibility of the CCS Authorization Representative is to communicate patient services authorization requests with all CCS service area counties, for the approximate 58 counties throughout the State of California, and requesting authorizations by submitting Service Authorization Request (SAR) forms. The CCS Authorization Representative works closely with case managers and ordering providers' office staff and external clinical professionals. On occasion and in conjunction with the unit supervisor, may interact with State Medical Directors to resolve individual account authorization or coverage issues. In general, the CCS Authorization Representative is responsible for all aspects of financially securing CCS insurance and authorization data for patient services. The CCS Authorization Representative's responsibilities include, though are not limited to: 1) verifying demographic and clinical information relevant to the patient's visit 2) verifying insurance eligibility and benefits, 3) securing authorizations, and 4) properly notating all activity in UCSF's APeX electronic health record system.

Responsibilities:

• Independently accountable and responsible for obtaining authorizations for all CCS population for inpatient admissions, outpatient surgeries/procedures and outpatient visits or services by working with ordering physician's office , the applicable Medical Center department, and/or review organization(s) as required for UCSF Medical Center and for UCSF physicians that perform professional services at UCSF Benioff Children's Hospital/Oakland.
• Confirms Medi-Cal eligibility and provides notification for established patients or initiates new patient referrals to CCS for inpatient admissions, outpatient surgery and procedures analyzing and identifying appropriate CPT (Current Procedure Terminology) procedural codes and ensuring that CCS insurance coverage is properly attached and documented in the electronic health record (APeX system). The Account Representative utilizes their specialized knowledge of insurance billing and reimbursement to maximize the return to the UCSF Enterprise. In the event that the inpatient admission or outpatient surgical procedures are rescheduled due to an authorization issue, protocol change, patient request, or any other event, the CCS Authorization Representative will ensure that all parties are informed including communicating with the provider's office to ensure that proper follow up is maintained.
• Confirm patient's complete insurance eligibility and benefits identifying any specific concerns that may delay the ability to secure authorization and update APeX or authorization request as necessary. This may include insurance coverage available and confirmed when CCS eligibility is verified on Medi-Cal website.
• Retrieves clinical information, completes appropriate forms and submits authorization requests for CCS population ordered by UCSF clinicians via patient work queues, Right Fax automated fax system, online submission, emails or telephone. Independently follows patient authorization determination and responds appropriately to provide additional information to all parties involved, monitors authorization status and updates referral status as needed.
• Communicates with physician staff, clinics, internal and external case management and pre-access department when authorization referral remains in "Pending" status or not submitted for review. Clinics request status update when accounts remain pending or no update has been received

The final salary and offer components are subject to additional approvals based on UC policy. Your placement within the salary range is dependent on a number of factors, including your work experience and this position classification at UCSF. This position is represented by a labor union; placement within the salary range will be guided by the rules in the collective bargaining agreement.