Payor Specialist - Toledo Hospital - Utilization Management

📋 Description

• • Serve as a Payor Specialist responsible for notifying payers upon patient admission at ProMedica and securing necessary authorizations for care.
• • Submit clinical documentation to payers in accordance with contractual agreements to obtain approval for appropriate levels of care and length of stay.
• • Accurately document all payer determinations, approvals, and denials within the Epic electronic health record system.
• • Communicate payer authorization requirements and decisions directly to unit manager nurses to ensure alignment with patient care plans.
• • Ensure compliance with insurance guidelines and federal regulations throughout the authorization process.
• • Work remotely with variable shifts across the United States, requiring flexibility to support hospital operations during non-standard hours.
• • Maintain confidentiality and accuracy in handling sensitive patient and payer information.
• • Collaborate cross-functionally with clinical teams to facilitate timely and compliant patient admissions and care transitions.
• • Adhere to ProMedica’s mission-driven standards for patient care, regulatory compliance, and operational efficiency.
• • Perform duties in alignment with job summary, recognizing that responsibilities may evolve beyond stated tasks to meet organizational needs.
• • Operate in a remote environment with consistent access to high-speed internet to ensure uninterrupted workflow and secure data transmission.
• • Participate in ongoing training and compliance updates related to payer policies, Epic system usage, and healthcare regulations.
• • Support utilization management goals by optimizing authorization processes to reduce delays and improve patient access to necessary services.
• • Maintain detailed records of all communications and authorizations to ensure audit readiness and regulatory compliance.
• • Work within a part-time schedule of 20 weekly hours, with variable shifts that may include evenings, weekends, or holidays as needed.