Note: The job is a remote job and is open to candidates in USA. The University of Miami/UHealth is a university-based health system providing patient care, research, and medical education. The Clinical Business Operations Representative 3 supports clinical operations by managing pre- and post-care administrative needs, patient information, communications, and records. The role specializes in processing complex prior authorizations, handling appeals, resolving insurance issues, and preventing delays in patient care.
Responsibilities
- Assists the department in managing expectations surrounding pre- and post-patient care
- Obtains or reviews all patient demographic information, insurance information, and referral numbers
- Reviews clinical records for completeness including authorization, signatures, missing data, and other patient information
- Answers multiple telephones for the department: triages incoming calls, responds to questions, directs calls, and documents messages in the appropriate software
- Greets visitors and callers, handles their inquiries, and directs them to the appropriate employee according to their needs
- Works cooperatively with fellow employees to solve problems and enhance the smooth and efficient flow of the practice
- Provides coverage for responsibilities of co-workers when assigned or as need arises
- Develops and promotes the use of effective methods of communicating with physicians, managers, peers, trainees, and staff on a regular basis
- Maintains confidentiality of all information
- Adheres to University and unit-level policies and procedures and safeguards University assets
- Process Prior Authorizations: Process PAs for medications, specialty medications, procedures, imaging, and other services within the required timeframe
- Review Requests: Make sure each request has the correct insurance, clinical information, medication details, and supporting documents
- Submit PAs: Submit requests to the correct insurance plan and monitor them until a final decision is received
- Follow Up: Follow up on pending PAs within the required timeframe to prevent delays in patient care
- Resolve Issues: Identify and resolve missing information, insurance issues, documentation needs, and other problems that may delay the PA
- Handle Denials and Appeals: Review denials and work with providers and clinical staff to obtain information needed for appeals or reconsiderations
- Communicate With the Team: Keep providers, MAs, CBORs, and clinical staff updated on PA status, approvals, denials, appeals, and outstanding information
- Verify Insurance: Confirm the patient's active insurance and make sure the PA is submitted to the correct plan
- Update Insurance Information: When needed, work with the patient or appropriate staff to obtain updated insurance information
- Document Accounts: Accurately document all PA activity, including submissions, follow-ups, calls, approvals, denials, appeals, and next steps
- Manage Workload: Prioritize urgent requests while managing daily workload and meeting required turnaround times
- Monitor Expirations: Track PA expiration dates and start renewals when needed to prevent gaps in treatment
- Handle Complex Cases: Work independently on complex cases and escalate issues when additional assistance is needed
- Improve Workflows: Identify common PA issues and suggest ways to improve workflow, reduce delays, and increase approvals
- Support Team Members: Help other CBOR team members with questions, complex cases, and payer requirements
- Stay Current: Keep up with insurance changes, payer requirements, PA criteria, and department processes
- Prevent Patient Delays: Work each PA from start to finish and address issues promptly to help prevent delays in medications, treatments, procedures, or imaging
Skills
- Minimum 2 years of relevant experience required
- Learning Agility: Ability to learn new procedures, technologies, and protocols, and adapt to changing priorities and work demands
- Teamwork: Ability to work collaboratively with others and contribute to a team environment
- Technical Proficiency: Skilled in using office software, technology, and relevant computer applications
- Communication: Strong and clear written and verbal communication skills for interacting with colleagues and stakeholders
- High School Diploma or equivalent/relevant experience, certification or license
Benefits
- Medical insurance
- Dental insurance
- Tuition remission
- Comprehensive benefits package
- Remote work
Company Overview
Company H1B Sponsorship