Lead Payor Specialist

About the role

Hybrid Schedule - 1st 6 months onsite, then Hybrid.

The Lead Payor Specialist reflects the mission, vision, and values of NM, adheres to the organization's Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.

The Lead Payor Specialist supports the Quality Utilization team to efficiently communicate with payors and ensure timely initial stay authorization and continued stay authorizations for acute care inpatients. This role leads the work of the Payor Specialists and collaborates with the Lead Quality Utilization Specialist to ensure effective/accurate communication of clinical information to payors.

This role leads the timely obtainment of payor authorizations by collecting and analyzing information to identify and resolve barriers in order to assist in achieving Clinical Quality Utilization goals. Includes escalating cases to the Quality Utilization leadership as appropriate.

Under the direction of the Manager, this position oversees and regularly checks the work of other Payor Specialists, provides training and orientation of new employees, and identifies and helps resolve staff and operational issues.

Responsibilities

• Leads the work of Payor Specialists within the department.
• Serves as a role model and resource to Payor Specialists and other staff regarding Payor Specialists Best Practices.
• Provides training and orienting to all Payor Specialists, and maintains training and orientation materials and records.
• Reviews cases escalated by the Payor Specialists for appropriateness and accuracy of documentation and process.
• Reviews cases escalated by the Quality Utilization Specialists that may have authorization challenges. Further escalates cases as appropriate.
• Coaches Quality Utilization Specialists and Payor Specialists on issues related to payor specifications, obtainment of authorization, and denial coordination.
• Promotes a professional and positive environment. Demonstrates teamwork and effective communication across units/departments and helps resolve operational issues.
• Participates in departmental quality improvement activities. Provides ideas and suggestions for process improvements within the department.
• Partners closely with Managed Care, Patient Access, Social Work and Financial Clearance departments as well external stakeholders.
• Cornerstone for Payor Specialist team to help identify and resolve complex issues by providing guidance, educational feedback and Best Practice process improvement opportunities.
• Serves as first line of assistance to staff. Investigates and resolves patient, technical and workflow problems related to their area of responsibility.
• Alongside QU leadership, helps coordinate and supervise section staffing to ensure sufficient staff to cover all aspects of service. Works proactively with Lead/management to adjust daily staff work assignments due to absences or increased patient volume.
• Consistently practices Patients First philosophy and adheres to high standards of customer service. This includes setting an example by fostering a team atmosphere.
• Forwards, directs and notifies QU leadership of extraordinary issues as necessary.
• Assists with data preparation and the creation of presentation materials as needed for the Quality and Documentation Team.
• Completes all assignments and duties of a Payor Specialist, including but not limited to:
• Collaborates with the QUS staff in order to effectively communicate accurate clinical information to payors to obtain pre-authorization, pre-certification, and continued stay authorization for appropriate levels of care and length of stay.
• Tracks and assures compliance with payor requests for information and communicates payor requests to appropriate QUS as needed.
• Communicates with and coordinates Onsite Payor Review activities to assure timely certification determinations.
• Documents and communicates denial and peer review information and patient out-of-network status and contact information to the QUS team.
• Other duties as assigned by manager.

Additional Functions

• Participates on departmental and hospital committees and taskforces as assigned.
• Complies with Northwestern Memorial Hospital policies on patient confidentiality including HIPPA requirements and Personal Rules of Conduct.
• Participates in hospital and department quality improvement initiatives.

Qualifications & Requirements

Required

• Bachelor's degree
• Minimum five (5) years of healthcare/related experience
• Conversant with medical terminology.
• Expertise and knowledge of third-party payor, Medicare/Medicaid guidelines.
• Advanced computer skills including word processing and spreadsheets.
• Experience in preparation of training tools and/or work flow design.
• Computer and database management skills to efficiently and effectively manage QU Department electronic systems, including Careport and Epic.

Preferred

• Master's Degree in healthcare-related field
• 7+ years of relevant experience
• Acquired certifications relevant to position

Additional Information

Background Check

If you are offered a position with us, you will be required to complete an authorization and disclosure form that gives Northwestern Medicine permission to run the background check. Results are evaluated on a case-by-case basis, and we follow all local, state, and federal laws, including the Illinois Health Care Worker Background Check Act.

Artificial Intelligence Disclosure

Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person.

Benefits

• We offer a wide range of benefits that provide employees with tools and resources to improve their physical, emotional, and financial well-being while providing protection for unexpected life events.
• Please refer to the Benefits Eligibility by Employment Classification to determine benefits eligibility for job postings.

If sign-on bonus is included in a job posting eligibility is as followed: Internal employees and rehires who left Northwestern Medicine within 1 year are not eligible for the sign-on bonus. Exception: New graduate internal employees seeking their first licensed clinical position as a Registered Nurse at NM may be eligible.