Purpose of Position
The Clinical Reimbursement Specialist is responsible for coordinating the services provided to managed care, high risk and reduced fee status clients admitted to the Agency and will ensure that the patient receives maximum benefit and quality of services in the most cost-efficient manner. Obtains pre- and re-authorization of service in collaboration with Agency staff, insurance representatives and case management representatives.

Description

1. Identifies managed care, high risk and reduced fee status clients and maintains current awareness of insurance coverage benefits and Agency policy related to same.
2. Ensures prior and re-authorization for services is obtained as per the individual insurer and maintains documentation of all authorizations for services.
3. In collaboration with the clinician, reviews clinical documentation for reimbursement including the parameters established by the individual insurer and the appropriate clinical practice guideline.
4. Provides individual and group staff education regarding managed care documentation guidelines, and serves as a contact person for Agency staff, insurance representatives and external and system case managers.
5. In collaboration with the clinician, provides case management of free care clients during the episode.
6. Provides timely insurance information to the Agency Accounts Receivable department.
7. Processes reconsiderations and appeals of denials for service, as appropriate. Review ongoing and retro-active reimbursement issues.
8. Provides standard interim reports to third party payers and contracting agents as required.
9. Facilitates communication between clinician and physicians and third party case managers regarding the patient's plan of treatment, as required to ensure quality, appropriate and cost-effective care and utilization of services.
10. Participates in patient case conferences as a resource regarding third party payer issues.
11. Expedites the identification of community resources and vendors for the Agency field staff, and assists in procuring the services and products when necessary.
12. In collaboration with the clinician, reviews goals for managed care and free care clients to ensure that the individual patient's needs are met throughout the continuum of care. Assists staff to identify strategies to improve resource utilization through the use of clinical practice guidelines and appropriate community resources.
13. Negotiates optimal reimbursement fees to maximize benefits to the patient and revenues to VNA.
14. Maintains updated managed care/reimbursement manuals.
15. Interprets Agency policies and criteria for service to insurers, fiscal intermediaries, patients, families, physicians and the public.
16. Other duties as assigned.

Qualifications

• Associates Degree or equivalent preferred
• 2-years clinical reimbursement. Experience in certified home care preferred
• Medical billing experience preferred.
• Knowledge of third party reimbursement and medical terminology preferred.
• Word processing and data entry skills required as well as organizational, problem-solving and communication skills required.