Payor Specialist

Summary

Ensures timely provision and flow of clinical information to and from third-party payors to support certification/approval of inpatient days and post discharge services. Communicates clinical reviews and refers payor questions to appropriate case management. Collaborate with Patient Financial Services, Administration, Physicians and Financial Counselors to ensure appropriate reimbursement from third-party, private and government payors, for medical services provided in acute care setting.

Cape Fear Valley Medical Center

Fayetteville, North Carolina

Coordination of Care

Clerical

Days (United States of America)

• Reviews patient medical records for private payors, and provides clinical information to support admission and continued stay review
• Performs retrospective insurance reviews and sends pertinent clinical information as requested by payors for those patients no longer inpatient
• Communicates payor concerns or requests, such as peer-to-peer reviews, payor request observation, for additional information to appropriate utilization management case manager
• Provides prompt payor feedback to case manager and/or social worker regarding patient discharge plan, enabling them to re-evaluate/re-direct current patient plan of care to streamline services, based on payor response
• Collects copies and transmits pertinent clinical and patient demographic information required to complete payor reviews
• Cross-trains to cover Department Secretary duties when necessary
• Other duties as assigned

• Associate’s degree required OR 4 years’ experience in managed care required
• Completed medical terminology course required

• Experience in managed care claims/reimbursement or other healthcare field preferred

• Knowledge of third-party payor requirements including managed care, reimbursement and utilization review
• Excellent computer and data entry skills (Microsoft Word/Excel required)
• Excellent verbal and written communication skills
• Ability to prioritize and process multiple tasks, responsibilities and work projects, demonstrating strong organizational and time management skills
• Ability to analyze related information, plan effective actions and follow through reliably to meet expectations
• Ability to function independently and as team member
• Strong customer service orientation
• Knowledge of English grammar, punctuation and spelling

• Some light carrying and lifting may be required
• Occasional walking may be required to access all areas of the Medical Center
• Ability to effectively communicate orally to patients, family members, personnel, and physicians
• Near visual acuity to proofread hand or typewritten materials
• Manual ability to use telephones and computer keyboard
• Position involves sitting for extended periods of time performing data entry into a computer

Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity