The Reimbursement Case Advocate (RCA) is responsible for supporting various reimbursement functions, including but not limited to Intake, Data Entry, Benefit Investigations, Call Triage, Prior Authorizations, Pre-Determinations, and Appeals support. The Reimbursement Case Advocate (RCA) responds to all provider account, patient, and internal inquiries in a timely fashion. The Reimbursement Case Advocate (RCA) will appropriately document all interactions with provider, payer and related customers into the Osiris Database system.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Acts as single point of contact and voice for all providers, patients and product / sales team.
- Serves as a patient advocate and enhances the collaborative relationship between, payer, provider and sales team.
- Initiates and coordinates the insurance verification for physicians, hospitals, and ambulatory surgery centers for all company products.
- Performs a detailed insurance verification for all product and applicable procedures to the degree authorized by the SOP of the program.
- Manages a regional case load.
- Provide assistance to physician office staff to complete and submit all necessary insurance forms and gather missing information in a timely manner.
- Tracks and follows-up on prior authorization and appeal requests when necessary.
- Provides all necessary documentation required to expedite prior authorization requests including demographic, authorization/referrals, National Provider Identification (NPI) number and referring physicians.
- Accurately records all reimbursement correspondence and research in the database per the assigned fields and required metrics.
- Analyzes data and draws valid and logical conclusions based on information provided by insurers and documented medical policies.
- Communicates insurance verification, prior authorization, and denied claim results to customers and answers all related questions.
- Provides exceptional customer service to internal and external customers; resolves any customer requests in a timely and accurate manner; escalates complaints accordingly.
- Prioritizes duties and tasks as necessary to ensure assignments are completed in a timely fashion. Reports any reimbursement trends/delays to Team Lead.
- Works on problems of moderate scope where analysis of data requires a review of a variety of factors. Exercise judgment within defined standard operating procedures to determine appropriate action.
EDUCATION
Bachelor’s degree preferred.
QUALIFICATIONS
- Previous coding and billing experience in the office, hospital, or ASC settings Experience in a reimbursement-based call center environment preferred.
- 1-3 years customer service, reimbursement experience preferred Knowledge of Medicare, Medicaid, and Private Insurer Reimbursement Methodology
- Experience with the prior authorization process for products/services
COMPETENCIES
- Able to interpret and analyze detailed medical policies Basic understanding of the benefits investigation process [deductible, out of pocket, benefits exclusions, etc.]
- Ability to communicate effectively both orally and in writing.
- Adept at handling sensitive and confidential situations
LOCATION
US-Field
Smith+Nephew provides equal employment opportunities to applicants and employees without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability.