Manager of Medical Insurance & Central Prior Authorization

Overview :

Manages the daily activities of Patient Access Medical Insurance and Prior Authorization departments to ensure high quality customer service and improve revenue cycle activities for prior authorizations, documentation, billing and claims. Understands regulatory and third party payer guidelines for admissions, discharges, ambulatory visits, diagnostic imaging, inpatient and outpatient services, billing, to ensure authorization functions and staff remain in regulatory compliance. Reviews SVR (Staffing Variance Reporting) to ensure that budget guidelines are met, and to provide appropriate resources based on the department volumes and activities. Oversees training, education, and staff development by department supervisor, leads, and trainers. Promotes cross training and develops staff to enhance job function and responsibilities so that maximum flexibility within Patient Access is achieved. Coordinates and communicates process updates and flows with internal departments at Carle and external departments when necessary, to ensure that Prior Authorizations are in place by the patient's service date to increase patient satisfaction, reimbursement to the organization, and problem resolution. Takes an active role in denials reduction efforts, timely filing expectations for registration and authorization claim error resolution, and serves as a SME (Subject Matter Expert) for Revenue Cycle operations for registration and authorizations.

Responsibilities :

• Continuously streamlines processes / systems to achieve maximum effectiveness
• Ensures employees are properly oriented and trained in operations and equipment, and annual competencies and certifications, licensures and education requirements are correct
• Ensures the accuracy and completeness of patient information entered into the EMR system
• Maintains payroll to ensure accuracy of man hours.
• Enforces various organizational policies consistently
• Manages daily activities of the Medical Insurance and Prior Authorization departments
• Ensure quality and quantity of work is maintained
• Ensure ordering and performing departments in patient authorizations is communicated in a timely manner
• Operates departments in a cost-effective manner by monitoring labor hours, supply expenses, and volumes.
• Ensures adequate staffing levels are maintained
• Provide timely patient service and submission of authorizations
• Performs department audits to identify authorization errors
• Provides continuous written and verbal feedback to staff and management regarding audit outcomes
• Assigns and delegates tasks as needed in the absence of employees so workflow is maintained
• Works closely with OR / Med Surgical leadership, ASC (Ambulatory Surgical Center) leadership, Revenue Cycle leadership, Specialty department leadership, Patient Financial Services, Inpatient Case Coordination services, Information Technology, payer contracting.
• Communicates necessary changes to appropriate department leadership to improve processes.
• Performs high level of patient service from all areas of responsibility.
• Assist staff with dealing with patient service and insurance service issues, utilizing Payer Contracting and Insurance Payer Representatives when needed
• Maintains active involvement with all regulatory compliance functions by maintain up to date working knowledge of latest healthcare trends in authorization, insurance verification and benefits, reimbursement, claims denials, and hospital / clinical management
• Identifies, discusses, plans and implements processes that align with state and government regulations as needed
• Monitor and analyze workflows and processes to ensure that operations e.g. registration, authorization, financial counseling, pre-service estimations and collections, and all other Patient Access Functions are optimizing the best outcomes for patients and the organization
• Lead employees in The Carle Experience with accountability of expectations by mentoring, coaching, discipline, etc.
• Perform audits to identify authorization errors while providing feedback to employees (i.e. WQ audits, documentation audits, Voicecert / Pixcert audits, WQ audits)
• Interview, hire, and onboard new employees with the assistance of department supervisors and peer interviewers, with a 90 day process as well as evaluations for new / existing employees
• Adhere to all leadership expectations of the Carle Experience through rounding, AIDET audits, Patient Experience scores, as well as benchmarking and 90 day action plans
• Manages budget and productivity targets within the department

Qualifications : Certifications :

Education :

Work Experience :

Carle Health Company Overview :

Find it here.

Discover the job, the career, the purpose you were meant for. The supportive and inclusive team where you can thrive. The place where growth meets balance and opportunities meet flexibility. Find it all at Carle Health.

Based in Urbana, IL, Carle Health is a healthcare system with nearly 16,600 team members in its eight hospitals, physician groups and a variety of healthcare businesses. Carle BroMenn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet designations, the nations highest honor for nursing care. The system includes Methodist College and Carle Illinois College of Medicine, the worlds first engineering-based medical school, and Health Alliance. We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information : human.resources@carle.com.

Salary Range :

The compensation range for this position is $36.86per hour - $63.4per hour. This represents a good faith minimum and maximum range for the role at the time of posting by Carle Health. The actual compensation offered a candidate will be dependent on a variety of factors including, but not limited to, the candidates experience, qualifications, location, training, licenses, shifts worked and compensation model.

Carle Health offers a comprehensive benefits package for team members and providers. To learn more visit careers.carlehealth.org / benefits.