The Lead Billing Specialistcollects, analyzes, and provides pertinent, timely clinical information including medications, clinical presentation, diagnosis and other information to payer sources and external utilization review personnel for authorization of inpatient stay and services of the initial, concurrent, and discharge authorizations and reviews which are completed through interactions with the client's insurance companies during normal business hours including, nights, weekend and holidays as necessary.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Obtain proper authorization for each admitted patient in all New Hampshire programs including the full continuum of care.
- Review and monitor each step of the authorization process to proactively identify and resolve problems.
- Interact with physicians, clinicians, and care team members on an on-going basis to assure patient assessment and treatment planning and appropriately gather all clinical information to determine the medical necessity of requested healthcare and to assure services are accurately and consistently reflected in facility documentation.
- Maintain a daily record in the Welligent system of the concurrent review process and inform the treatment team of the authorization status of each assigned patient.
- Develop and document accurate pay source information in the EMR - Welligent.
- Follow up with Care Team to ensure that patients access the full range of their benefits through creative utilization.
- Work with Care Team to ensure accurate documentation and billing processes to extend patients treatment stay as needed or deemed medically appropriate through maximization of benefits and minimizing appeals.
- Gather information each patient's individual needs on the basis of assessment and data collection to ensure proper admission for each level of care.
- Responsibility to follow up on denials, claims all the way through revenue cycles (ie: responsible for peer review, all denials and appeals process)
- Utilize Welligent effectively and efficiently.
- Communicate with clinical or care team staff on a regular basis regarding patient's progress and treatment plans.
- Discharge patients in accordance with established policy, discontinue pay sources and other Welligent and/or policy expectations/documentation.
- Carry out administrative procedures in compliance with program policies.
- Ensure program compliance with all CARF, DEA, BDAS, local, state and federal regulations and licensing requirements.
- Assist with and ensure the completion of all reviews including initial, concurrent, retro authorizations and discharge with insurance company and input the authorizations into the Welligent system according to compliance.
- Accurately report and maintain BDAS billing for New Hampshire programming.
- Maintain all state insurance contracts and billing process (NH and VT, etc.)
- As needed, attend treatment team in all New Hampshire locations to review billing violations, trends, company expectation and/or billing changes.
- Communicate directly with Administrative Program Directors regarding presenting financial, clinical and/or other presenting concerns related to programmatic development.
- Communicate on a regular basis with PHNE Financial Department.
- Perform other duties as assigned.
§ Demonstrates compassion, empathy and respect for patients and staff in all interactions.
§ Demonstrates knowledge and understanding of insurance, clinical review, ASAM, and other utilization review information.
§ Maintains objectivity and appropriate boundaries toward patients, stakeholders and staff through thoughtful decision-making, based upon accurate information.
§ Serves as a role model through positive, appropriate conduct, attire and participation in special agency events. Projects a positive and professional image to the public.
§ Demonstrates patience and consideration in all dealings.
§ Ensures employee and patient confidentiality regarding all information and records in accordance with local, state and federal statutes.
§ Models Phoenix House "Every Time Behaviors".
§ This position may require periodic travel to other sites within the region.
KNOWLEDGE, SKILLS & ABILITIES
To perform this position successfully, you must be able to perform each essential duty and responsibility satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties and responsibilities. The requirements listed below are representative of the knowledge, skill and/or ability required.
§ Skill in treatment of substance abusing populations, and in co-occurring mental health disorders
§ Extensive knowledge of the daily operations of a not for profit substance use disorder treatment facility.
§ Ability to prioritize conflicting demands/expectations as well as to multi-task effectively for sustained periods of time.
§ Knowledge of rules and regulations related to HIPPA and 42 CFR Part II.
§ Proficiency in operating software programs to type documents, manage databases, presentations and create spreadsheets.
§ Ability to apply organizational and time management to meet competing deadlines.
§ Ability to maintain appropriate boundaries with staff and residents.
§ Ability to comply with all state and federal regulations, including confidentiality (HIPAA and Employee Records and all other confidential materials).
§ Ability to collaborate and build successful relationships with others to ensure objectives and goals are met.
§ Ability to apply organizational management skills and maintain self-discipline
§ Communication skills both written and verbal as well as the understanding of the principals of communication in multiple directions, vertically, horizontally and laterally.
§ Problem solving skills with a "solution oriented" mind-set.
§ The ability to be forthcoming with information and/or personal challenges to ensure the facility Program Director has an accurate awareness of any issues that may impact him/her or his/her program as well as his/her staff or other members of Phoenix House.
§ Accountable and Dependable.
EDUCATION/EXPERIENCE: Associate degree or higher in an appropriate field from an accredited institution with an equivalent combination of education and experience within the field of business or related field.
LICENSES/CERTIFICATIONS: Not required at this time, LADC, CRSW, is preferred
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties and responsibilities of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties and responsibilities.
You are required to remain awake for the entire shift.
Sit, use hands to finger, handle or feel objects, tools or controls; reach with hands and arms, and talk or hear.
OCCASIONALLY REQUIRED: to stand, walk, stoop, kneel or crouch and lift and/or move up to 10 pounds
The work environment characteristics described here are representative of those an employee encounters while performing the essential duties and responsibilities of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties and responsibilities.
The work environment is that of a substance abuse treatment milieu which may include:
§ Exposure to patients infected with Hepatitis B, HIV, TB, or other Infectious Diseases
§ Exposure to patients with co-occurring mental health issues.
§ Business-related travel may be required
Monday - Friday, may require nights, weekends, and holidays as needed and the ability to be available by telephone as needed.
Phoenix House is an Equal Opportunity Employer providing equality of opportunity to all who are protected against discrimination by law, regulation or executive order, including veterans and individuals with disabilities. EEO is the Law: Applicants and employees are protected under Federal law from discrimination. Click www.dol.gov/ofccp/regs/compliance/posters/pdf/eeopost.pdf to learn more.