Practice CRD 3

As a patient-focused organization, UCSF Medical Center exists to enhance the health and well-being of people through patient care, research and education. Success in this mission requires a culture of collaboration, excellence, leadership, and respect. UCSF Medical Center seeks faculty and staff that are committed to the values of professionalism, respect, integrity, diversity, and excellence that are integral to our mission.

The PC Authorization Coordinator is primarily responsible for securing financial clearance for the patient, provider, and health system. The coordinator works closely with the administrative, clinical and management teams to support practice operations and customer service recovery and intervention efforts. Provides support for financial clearance functions including authorizations, PAFRs, LOAs billing and RFIs.

Under the direction of the Revenue Manager and/or supervisor, the biller/auth rep will work independently to resolve billing related issues in APeX (Epic) to help maximize payor reimbursement and RVU charge capture. He/she must have an advanced understanding of healthcare terminology, processes and workflow and healthcare billing/authorizations in order to make good decisions and resolve account issues. The incumbent should also have outstanding people skills, including telephone technique, professional appearance, organizational skills, and communication skills (oral and written).

This position will also be responsible for performing detailed review of medical record documentation to answer billing/authorization level questions and will be responsible for working assigned authorization and billing work queues (WQs) on a daily basis to assist in keeping the denials at a minimum. He/she must have the ability to prioritize multiple tasks and work well with all levels of staffing including faculty, management, and coworkers both within and outside of the unit.

The PC is responsible for the maintenance of all routine clerical operations and communications. Adheres to the UCSF House and Telephone Standards and is sensitive to the needs of patients, staff and providers at all times. The PC is a team player who works closely with others and who is flexible in dealing with the changing priorities.

Requires a self-reliant individual who synthesizes knowledge of practice operations in order to problem-solve, prioritize and facilitate complex transactions in the course of daily activities. This position makes a difference for patients in an outpatient care unit by providing excellent customer service, facilitating and ensuring the accuracy of the information flow between medical, hospital staff and departments to maximize unit efficiency.

The PC is required to work at any UCSF campus as needed and scheduled.

• Day shift Responsibilities New & Follow-Up Patient Authorizations 5%
• On a daily basis review and works authorization work queues documenting activities within the authorization record.
• Reviews referral work queues as needed to monitor incoming volume.
• If a practice utilizes an external system for specialty authorizations, such an electronic log, the representative maintains the electronic log but also creates an authorization record for accurate tracking and documenting financial securitization.
• Enters or updates patient registration information as needed to correct errors.
• Ensure appropriate insurance is loaded and facilitates authorization acquisition. Verifies insurance and referral/authorization information from previous appointments as needed to facilitate subsequent authorizations. Schedules and coordinates any pre-appointment tests or appointments.
• Schedules and coordinates any pre-appointment tests or appointments.
• Creates HARs [Hospital Account Records] as needed to facilitate authorization loading.
• Creates a professional and positive first impression for patients and referring physicians. Demonstrates good judgment and common sense. Advanced New & Follow-Up Patient Authorizations 15%
• Secures outside medical records, as needed for authorizations makes quick determination on services known for long authorization turn around or not needing the authorization. as to which physician can best evaluate the patient.
• Understands and is able to prioritize authorizations based on clinical complexity, diagnosis and current treatment status to ensure authorizations are prioritized appropriately. Has expertise in understanding payor timelines to know when authorizations need to be started urgently due to payor constraints and ensure that as many patients are authorized successfully as possible.
• Informs practice personnel, providers are patients as needed of authorization delays and denials in a timely manner.
• Escalates authorization delays ASAP for services to patients within 72-hour window or for urgent or medically sensitive services. Surgical Authorization Coordinator 5 % * depends on practice
• Coordinates securing authorizations for all outpatient and inpatient surgeries for the surgical practice. Captures appropriate CPT and ICD-10 codes, or coordinates with provider, or certified professional coder to acquire accurate codes.
• Interacts with clinical and academic staff to coordinate surgical activities depending on authorization availability.
• Coordinates and manages complex referrals and authorizations including LOAs, Psych, Lab, Imaging and other specialties. Advanced Surgical Authorizations 15%
• Coordinates with practices, PAR, Admitting and other related departments to coordinate securing all necessary authorizations. This could include procedure, admissions, medications, labs, imaging and testing services. Additionally, many cases require complex admission, discharge and planning coordination involving hospital reservations and authorizations related to study patients on protocol, transfers from outside hospitals and post transfer urgent authorizations and surgical planning.
• Works with patients and staff to confirm availability and accuracy of medical information within APeX and to ensure documentation supports medical necessity.
• Secures authorization for surgical procedures and coordinates with Hospital Admissions Department as needed. Acts as primary liaison to procedure billing team to coordinate updated authorizations and or TARs for mid procedure changes or additions.
• Ensures compliance with Medical Center bylaws and Regulations ensuring the diagnosis is confirmed before authorization through formal review of relevant clinical information. The authorization coordinator is the sole person to ensure authorization is secured for the organization.
• Coordinates advanced authorization for complex services such as psychotherapy, psychiatry, IVF, serial service testing and imaging.
• Must have extensive payor expertise to coordinate complex authorizations for multiple surgical practices (i.e. Ortho Surgery, Urology Surgery etc.) Revenue Cycle <5%
• Ensure that authorizations are secured with accurate clinical information and with support for medical necessity.
• Communicates Medical Center administrative and financial policies clearly to patients, answering patient account questions and knowing when to refer patients to financial counseling, billing agents, patient relations or other support departments for additional help.
• Obtains and documents insurance authorizations for established patient visits, referrals and procedures or ancillary services. Communicates clinical information from medical records authorization requests to insurance companies.
• Demonstrates competency working with CPT codes and ICD-9 and ICD-10 for the purpose of scheduling and securing authorization.
• Works with patients and staff to confirm availability and accuracy of medical information within APeX and to ensure compliance with all hospital policies and procedures.
• Able to identify and escalate outstanding issues to appropriate supervisor or manager.
• Addresses patient billing questions and triage calls as needed. Provides requested documentation such as operative reports, doctor’s notes and insurance information to aid in the reimbursement process.
• Obtains retro authorizations of procedures while maintaining current list of those insurances with a history of denials (this includes pre-service, post service, retro/modifications and appeals if needed.) Moderate Complex Revenue Cycle 5%
• Monitors provider(s) open authorizations to ensure that patient services can be rendered in a timely manner and meeting clinical timelines as much as possible.
• Works RFI work queues to secure information for accurate billing submissions or to respond to denials such as retro authorizations, clinical documentation, and addended authorizations with add on CPT codes.
• Secures authorization for procedures, specialty visits and ancillary testing and coordinates with Hospital Admissions Department as needed.
• Secures assistance with complex DME authorizations that often require precise documentation in specific formats to receive approval
• Provides assistance with medication authorization for new medications and refills. Advanced Revenue Cycle 15%
• Secures complex insurance authorizations for services, medications, or testing and is able to track the authorizations for renewal based on insurance company driven limits of time frames or numbers of visits or services.
• Has demonstrated competency working with HCPC codes and is able to look up and locate the appropriate codes for the purpose of requesting authorization (e.g. J codes for medications like chemotherapy).
• Understands how to identify and interpret a patient’s insurance benefit package, including pharmacy and mental health carve outs. Utilizes this information to direct authorization requests and to coordinate these services for patients.
• Reviews & analyses monthly denial reports for both professional and hospital billing. Initiatives retro authorizations from denial report.
• Identifies trends in denials and works with practice team and supervisors to develop and implement improved workflows to minimize denials.
• Compiles & analyzes data for reports to track basic revenue cycle measurements such as charges, payments, visit volume, etc. and creates reports in Microsoft Excel.
• Oversees and coaches staff on complex authorization requests as they arise.
• Address patient complaints from patients regarding authorizations that come out of Patient Relations.
• Through reporting track patterns of authorization complaints and identify patterns which need to be escalated to unit management for potential escalation to UCSF payor contracting and Faculty Practice leadership.
• Understands the concept of managed care and is knowledgeable about the resources available to the staff in regard to knowing the specific requirements of individual managed care plans. Reviews all upcoming authorizations to determine patient eligibility and adjusts authorization retrieval as needed.
• Department resource for insurance questions and insurance updates, including having reserved time on the staff agenda to review updates with administrative team, include important updates in the practice newsletter including drafting newsletter announcements Customer Service 5%
• Provides excellent customer service working with providers, colleagues and practice coordinators using AIDET standards.
• Gives priority to urgent authorizations and is aware of the necessity of maintaining practice flow, paying careful attention to the performance improvement initiatives to reduce delays.
• Communicates with patients in a confidential professional manner using tact and diplomacy as applicable. Care Coordination Responsibilities <5%
• Secures patient authorizations using Apex and its related components.
• Understands the distinction of each medical practice and how care is delivered in each setting.
• Coordinates authorizations with multiple providers.
• Discusses authorization policies and procedures for the appropriate facility and timeliness with practice coordinators, managers and providers.
• Answers questions about authorizations and acts as a resource to other medical center practices and ancillary service administrative staff.
• Adheres to productivity standards as established by the unit and meets or exceeds set standards.
• Utilizes legacy systems and Apex to retrieve pertinent patient data.
• Obtains access to all patient authorization forms, insurance portals/databases and utilizes them to submit , track and secure authorizations as efficiently as possible.
• Covers authorization WQs and phone messages when other members of the team are absent.
• Demonstrates an ability to adjust priorities as required for smooth operation the unit and ensure urgent authorization priorities are being met.
• Provides all authorization support to providers in coordination of patient care.
• Collaborates with clinical staff in problem-solving patient needs and requests for same day appointments and other appointments requiring authorization coordination. Works together with the clinical staff in the processing and follow-through of urgent patient needs.
• Demonstrates courtesy and overt helpfulness in all interactions. Collaborates with unit Supervisor and Administrative Director in the resolution of patient complaints.
• Demonstrates courtesy and overt helpfulness in all interactions. Collaborates with unit Supervisor and Administrative Director in the resolution of patient complaints.
• Assists in maintaining current filing and scanning. Moderate Care Coordination Responsibilities <5% Must have an understanding of multiple clinical urgencies and their associated escalation level for authorizations with a commonsense approach for when it is appropriate to escalate or take action to speed along a process.
• Advanced customer service skills in working with and providing exceptional customer service to patients who are medication dependent and may exhibit challenging behaviors. This includes understanding how to deescalate a difficult encounter and also when to seek additional support from leadership and to protect the safety of the work environment. Advanced Care Coordination Responsibilities 10%
• Acts as liaison with practices and providers. Expedites requested services.
• Coordinates complex patient care as needed.
• Keeps track of patients who have parallel pathways for their medical care and works with clinical providers to take steps at critical points along the continuum if there are authorization limitations.
• Directly obtains or works with Radiology to obtain complex imaging authorizations.
• Identify authorization problems; report out to management team with suggested solutions.
• Develop and review reports related to authorization management, tracking and updating manageme Required Qualifications High School graduate or equivalent with four years related experience; or college degree and 6 months related experience; or equivalent combination of education and experience. Successfully passes fingerprinting protocol and is approved to be a cash collector if applicable. Strong computer skills, including basic keyboarding skills, and experience with at least two Office-type software programs (i.e., Outlook, Word and Excel). Proven ability to navigate through multiple patient records systems. Able to sit at a computer terminal with telephone headphones for extended period of time. Ability to analyze situations, prioritizes, and develops solutions and makes recommendations. Ability to work with minimal supervision Ability to use good judgment and work independently, at times under the pressure of deadlines Ability to access situations prioritizes workload, develop solutions and make recommendations. Excellent customer service and communication/interpersonal skills, both over the telephone and directly. Able to sit at a computer terminal with telephone headphones for extended periods of time. Basic math skills required. Proven ability to deal with a wide variety of individuals; Ability to deal sensitively and effectively with patients. Excellent organizational and problem-solving skills. Strong writing skills to include the ability to compose, edit, and proof a wide variety of documents. Demonstrated administrative/office coordination skills. Demonstrated knowledge of medical practice terminology. Within six months of start date, based upon completion of training, the Supervisor, completes the proficiency checklist with the employee. This includes the following areas if applicable Referrals (Incoming referral entry) and handling all referral WQs Schedule surgeries Work applicable work queues Enter/edit outside test results Messaging (CRM) if applicable 2nd calls in CRM if applicable Telephone encounters My open encounter Staff message New message Route Patient advice request to providers (My Chart) Patient Schedule (My Chart) Letters Pools Patient look up Check in process Check out process Comment field Quick note Scanning

Demonstrated experience in health care (may include medical, dental or veterinary) in the following areas: patient scheduling, insurance verification, medical record data abstraction, or patient financial services. Prior experience with appointment, ancillary service or surgical scheduling or a combination of all three. Bi-lingual or multi-lingual capability (Spanish, Cantonese, and Russian) strongly preferred.

Prior experience with EPIC.