CRM Integration Specialist is responsible for Customer Relationship Management (CRM) system integration. Ensures all functions of CRM system effectively work with all other applications and operating systems. Being a CRM Integration Specialist requires a bachelor's degree in area of specialty. Typically reports to a manager or head of a unit/department. The CRM Integration Specialist supervises a group of primarily para-professional level staffs. May also be a level above a supervisor within high volume administrative/ production environments. Makes day-to-day decisions within or for a group/small department. Has some authority for personnel actions. To be a CRM Integration Specialist typically requires 3-5 years experience in the related area as an individual contributor. Thorough knowledge of functional area and department processes. (Copyright 2024 Salary.com)
Responsible for performing the medication authorization functions with insurance carriers. Coordinate with/educate physicians, nursing staff and other health care providers on the authorization process and requirements. Works as a patient advocate and functions as a liaison between the patient, staff and payer to answer avoid care delays. Tracks, documents, and monitors authorizations. Implements check and balance systems to ensure timely compliance. Processes complete prescription claims including proper adjudication/reconciliation, insurance verification, prior authorization, and compassionate care/medication assistance programs associated with patient accounts and insurance claims billing.
Essential Job Functions
•Supports and models behaviors consistent with Billings
Clinic’s mission, vision, values, code of business conduct and service
expectations. Meets all mandatory organizational and departmental requirements.
Maintains competency in all organizational, departmental and outside agency
standards as it relates to the environment, employee, patient safety or job
performance.
•Coordinates medication authorization process ensuring
authorization has been obtained.
•Identifies and initiates precertification/authorization
requirements for individual payers and communicates with payer sources in a
timely manner to obtain necessary pre-certification/authorization.
•Processes complete prescription claims including proper
adjudication/reconciliation, insurance verification, prior authorization, and
compassionate care/medication assistance programs associated with patient
accounts and insurance claims billing.
•Enters medication charges and credits for the
adjudication/reconciliation of patient accounts and insurance claims billing.
•Participates in quality improvement activities utilizing
performance improvement principles to assess and improve quality.
•Documents and maintains patient specific
precertification/authorization data within the required information systems.
Documents and tracks authorizations using established process.
•Reports denials and/or delays in the
precertification/authorization process to physicians/other health care
providers and/or the patient.
•Develops and maintains collaborative working
relationships with payers and health care team.
•Reports non-compliance issues to department specific
leadership team.
•Works with Medical Staff Office validating provider
enrollment and NPI numbers.
•Tracks and verifies that medication
precertification/authorization has been received either verbally or written.
•Communicates status to health care team and patient as
needed. Reviews schedules and work lists multiple times throughout the day.
•Reports medication denials and/or delays in the
authorization process to the health care team and the patient. Provides
information to the patient on the appropriate appeal process for denials as
needed.
Additional Duties: Concurrent – Authorization
•Understands insurance/payer policy language, benefits
and authorization requirements upon admission, for concurrent review, and for
discharge.
•Coordinates Peer to Peer reviews. Submits letters of
medical necessity and follows up on payer denial outcomes.
•Participates in continuing education, department
planning, work teams and process improvement activities.
•Conducts follow-up calls, as necessary, to third party
payers to complete authorization process validating that all days are
authorized.
•Facilitates retro-authorization process with payers.
Communicates outcome with patient, physician, Patient Financial Services and
other key departments
•Responsible for coordinating resolution of varied
problem situations and performing necessary investigation and research as it
relates to the authorization process to resolve pre-certification/authorization
problems.
•Works closely with Payer Relations coordinating needed
pre-certification/ authorizations for in-network and out of network services.
•Maintains reference manuals that outline the individual
payer requirements as it relates to precertification and authorization needs
while also being responsible for the integrity and accuracy of the payer data.
•Responsible for the orientation and education of
physician, nursing staff, who rely on the pre-certification process.
•Works with Coding Resources validating correct and
billable CPT code, Writes process with critical elements for new procedures and
maintains pre-certification instruction manual.
•Reviews, updates and standardizes forms and processes as
needed.
Initiates workflow for new procedures/service lines.
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