Position Objective:

The Sr. PAVE Coordinator is responsible for initiating Pre-Authorization request to the payer for the claims that require approval. This position require communication with payers, patients, physician offices and hospital clinical staff. This position is primarily responsible for pre-certifying procedures ordered by physicians. The Sr. PAVE Coordinator will also be responsible monitoring appropriateness and medical necessity and provides necessary information for authorization and continued visits.  This individual will confirm pre-certifications that have been obtained or will obtain pre-certifications if needed in addition to conducting quality assurance.

Essential Job Duties:

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Serve as primary resource for LH regarding insurance eligibility; prior authorization process and requirements; collects patient demographic information and coverage information. Advises patients of their financial obligation and collects payments in a courteous and professional manner.
2. Contacts insurance companies by phone, fax, or online portal to obtain insurance benefits, eligibility, and authorization information;
3. Updates systems with accurate information obtained; performs quality assurance audits and reports back to leadership opportunities for providing education to patient access
4. Responsible for communicating to service line partners of situations where rescheduling is necessary, due to lack of authorization or limited benefits and is approved by clinical personnel;
5. Ensures that proper authorization is in place for inpatient, elective, outpatient, surgical, urgent/emergent services and held responsible for timely notification to payers of the patient’s visit to the facility to protect financial standing of the organization. Escalates non-authorized accounts/visits to management;
6. Ensures all benefits (Copays, Deductibles, Co-Insurance, OOP, LTM), authorizations, pre-certifications, and financial obligations of patients, are documented on account, clearly, accurately, precise, and detailed to ensure expeditious processing of patient accounts and denial prevention.;
7. Maintains a close working relationship with clinical partners, and ancillary departments to ensure continual open communication between clinical, ancillary, and Patient Access & Patient Financial Services, Surgical Scheduling departments. Case Management, and Utilization Review to facilitate the sending of clinical information in support of the authorization to the payer, as assigned;
8. Monitors team mailbox, e-mail inbox, faxes, and phone calls responding to all related PAVE account issues, within defined time frames; Adheres to the department accuracy and performance standards.
9. Contact payer to obtain prior authorization. Gather additional clinical and or coding information, as necessary, in order to obtain prior authorization;
10. Provide standardized documentation within system to identify prior authorization and the criteria surrounding such authorization; Verify that all insurance requirements have been met; Notify patient, Provider’s Office, Scheduling and Financial Counselor immediately when insurance coverage is inadequate or has been terminated.
11. Advises providers and their clinical staff when issues arise relating to obtaining prior authorization; educate providers and their clinical staff regarding the prior authorization process.
12. Stay informed and research information regarding insurance criteria for prior authorization; Attend department staff meetings, professional education sessions, complete e-learnings and mandatory training.
13. Performs other duties as assigned by PAVE Leadership.

Educational/Experience Requirements:

• Minimum three (3+) years of experience in Medical Billing, Hospital Patient Access, or Hospital Business Office in an automated setting.
• Knowledge of registration, verification, pre-certification, and scheduling procedures.
• Experience with Medical and Insurance terminology (ICD-10, CPT 4)
• Minimum of one (1+) year of demonstrated strong analytical skills
• Proficiency with Microsoft Office and Outlook
• Excellent verbal and written communication skills.
• Preferred experience with the Epic Hospital Billing System

• Bachelor’s Degree Accounting, Finance, Business Administration or Healthcare related field preferred
• Minimum three (3+) years of Revenue Cycle Experience in lieu of degree

Required License/Certifications: 

• One (1+) or more certifications from AAHAM, NAHAM or HFMA required.

• Healthcare Certification 
• 1 or more Certifications required:
• CRCE - Certified Revenue Cycle Executive
• CRCP- Certified Revenue Cycle Professional
• CRCS- Certified Revenue Cycle Specialist
• CHAM – Certified Healthcare Access Manager
• CHAA- Certified Healthcare Access Associate
• CHFP- Certified Healthcare Financial Professional
• CRCR- Certified Revenue Cycle Representative

Working Conditions, Equipment, Physical Demands:

There is a reasonable expectation that employees in this position will not be exposed to blood-borne pathogens.

Physical Demands -

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.

The above job description is an overview of the functions and requirements for this position.  This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.