Everyone who works with Mercy Health is united under one purpose: to help our patients be well in mind, body and spirit. This drive, along with our history of faith, is a powerful combination. It gives us a shared calling to work toward every day. Join our exceptional team and help us continue to provide the highest quality of health care possible to our communities.

Up to $12,500 Sign on Bonus Available!

Primary Function/General Purpose of Position

Position is accountable for evaluating, clarifying, and determining the financial risk involved for the Market-wide program, including the physicians, and patients as services are required. This includes determining the patient’s benefits available for evaluation, pre-service maintenance, admission, and post-service follow-up care; obtaining inpatient and outpatient authorizations for hospital and physician services; and ensuring necessary communication occur between the payor, and the hospital for appropriate and accurate billing and reimbursement of services.

Essential Job Functions

Obtains, clarifies, and documents the timely receipt of financial authorizations and benefits of patients requiring evaluations, hospitalizations, and all other related inpatient or outpatient services.
Determines scope of patients’ benefits including but not limited to coverage for hospital, physician, outpatient, pharmacy, home health, organ procurement, rehabilitation, and Durable Medical Equipment services.
Obtains necessary authorizations for hospital and physician services to be provided either in the inpatient and outpatient setting. Transmits the verification numbers and billing information to the appropriate financial and pre-auth departments and the various physician offices.
Performs re-certification on all inpatients, coordinating communications between the clinical coordinators, physicians, social workers, the hospital utilization review coordinators, the patient/family, and the payor.
Ensures interactions with third party payors case manager and contraction managers occur timely, accurately, and professional. These activities included but are not limited to:
Initiates discussions with payor regarding any need for and individual contract to be negotiated as patients are referred to the program center, hospital or other location. Notifies appropriate managed Care specialist who will negotiate with payors as necessary.
Performs written correspondence to payors to obtain and to send information and letters of medical necessity and participates in on-site payor visits to the program center.
Monitors and identifies changes in regulations and legislation with regard to Medicare of third-party payor reimbursement and updates program director(s) Medical Directors, and any other necessary administration in a timely manner.
Assist in the ongoing education of department staff regarding updates in contracts, Medicare reimbursement, and outside resources available to patients.
Presents in-services to staff, hospital financial staff, and physician office staff regarding managed care updates and assists in development and implementation of communications systems to send and to receive clinical and financial data between the program center and Patients referring physicians, treating physicians, and payors.
Participates in necessary professional organization, meeting, etc. to remain current of financial and reimbursement issues that may impact patient care.

This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job-related duties as required by their supervisor, subject to reasonable accommodation.

Licensing/Certification

None

Education

Bachelor of Science Nursing, Education/Healthcare Administration or other related field (required)

Work Experience

3 years’ experience in clinical health care patient accounting, admitting, utilization review, quality assurance or case management (required)

5 years’ experience in clinical health care patient accounting, admitting, utilization review, quality assurance or case management (preferred)

Many of our opportunities reward* your hard work with:

Comprehensive, affordable medical, dental and vision plans
Prescription drug coverage
Flexible spending accounts
Life insurance w/AD&D
Employer contributions to retirement savings plan when eligible
Paid time off
Educational Assistance
And much more

*Benefits offerings vary according to employment status

All applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, genetic information, or protected veteran status, and will not be discriminated against on the basis of disability. If you'd like to view a copy of the affirmative action plan or policy statement for Mercy Health – Youngstown, Ohio or Bon Secours – Franklin, Virginia; Petersburg, Virginia; and Emporia, Virginia, which are Affirmative Action and Equal Opportunity Employers, please email recruitment@mercy.com. If you are an individual with a disability and would like to request a reasonable accommodation as part of the employment selection process, please contact The Talent Acquisition Team at recruitment@mercy.com

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