Practice Coordinator III

DUTIES & ESSENTIAL JOB FUNCTIONS

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 management team with ongoing outgoing and incoming authorization issues as they arise; by payor, service line, service type etc.

• Assists teammates with complex care or payor authorizations to ensure they are obtained as soon as possible.

• Escalate delays in authorization that could potentially put the patient or organization at financial risk.

APeX and IT Specific Skills <5%

• Performs the following APEX specific Patient Care Coordinator (PCC) functions as appropriate to completion of APeX PCC training and job duties:

• Enter authorization information as appropriate. Documenting in authorization record. o Works applicable APeX work queues to address authorizations. o Complete and load authorization forms via 50+ authorization portals o Create and route patient letters associated with authorizations

• Create and route insurance authorization forms and letters to all carriers utilized by UCSF

Health o Works applicable APeX work queues to address patient care and service matters

Telephone Communications 5%

• Responds to telephone calls from practices or providers with authorization queries.

• Utilizes the EPIC Appointment Scheduling System (Cadence) to check patient appointments to facilitate authorizations and support scheduling.

• Documents call information in the EPIC CRM in a concise, accurate manner.

General Performance <5%

Completes Authorizations and related activities for a minimum of 3 departments, one to be of sufficient size and scope to qualify as complex (e.g., Cardiology). Is fully cross trained and able to support a minimum of 3 to 5 departments.

• Scans and imports authorizations and related documents like Letters of Agreement [LOA] in APeX system following established guidelines and policies.
• Upholds UCSF Medical Center policy regarding the maintenance and confidentiality of medical records and other patient information. Maintains and adheres to patient confidentiality and HIPAA guidelines including the distribution of NOPPs (Notice of Privacy Practices).
• Participates in team building by actively contributing during meetings and with staff and providers in discussion of all practice activities.
• Attends training classes provided by Medical Center, Billing Agent, and others as necessary. Bring information back to practice and use on the job.
• Works with supervisor and co-workers to ensure that the practice responds efficiently to authorization needs through improved procedures and administrative systems. Is an active participant in performance improvement projects and customer service initiatives.

• Complies with all Medical Center and Ambulatory Services procedures for infection control, safety, administrative and clinical practice. Complies with activities mandated by Joint Commission, Title 22.

• As assigned, fills in for other co-workers to help address workload problems and cover vacation or sick leave openings.

Moderate Complex General Performance <5%

• Works authorizations for 3 - 5 departments to include all authorization types in the unit.

• Provides 1:1 and team training for new hires and new initiatives and procedures Advanced General Performance 10% 

• Facilitates coverage as needed for authorization unit specialty team (e.g. when float is assigned, work with float to ensure successful coverage of work)

Environmental Responsibilities: <5%

• Reports any malfunctioning of equipment.

• Complies with recommendations made by ergonomic specialists to avoid workplace injury

• Complies with infection control policies related (e.g. does not eat at the front desk or in patient care areas)

Moderate Complex Environmental Responsibilities <5%

• Serves as practice deputy for life / safety activities helps lead drills Customer Service Outreach <5% 

• Deals directly with practice coordinators, providers, management and patients either by telephone, electronically or face to face while consistently following EVERYDAY PRIDE principles in verbal and written communications

• Responds promptly and courteously to internal and external inquiries. Stays logged into appropriate APeX WQs and In Baskets.

Supports all performance improvement initiatives as outlined by the Medical Center leadership through active participation and initiation

• Obtains and evaluates all relevant information to handle inquiries and complaints

• Strong team player, has a dedicated work ethic, and is willing to learn and adapt to new tasks when asked. Comfortable building rapport with internal and external team members quickly and is able to work effectively with and without supervision and remain calm and friendly in all interactions.

• Notifies providers of patient delays and service issues per established escalation protocols.

• Offers suggestions for change or improvement in clinic/practice operations.

• Leads by example in the areas professional appearance, demeanor and body language, making eye contact with patients and internal customers, exhibits a friendly demeanor to put patients at ease.
• Seeks opportunities to improve patient convenience. Utilizes service recovery amenities as appropriate. Contributes to the development of a patient-focused environment. Lead role duties 10% 
• Addresses and resolves escalated issues of day-to-day operations (e.g. customer service, provider complaints, cross departmental communication or coordination problems, etc.)
• Serves as a liaison to management to advise on, take lead action on, and provide direction on process improvements initiatives
• May function as a primary resource for one or more designated functions in the department (e.g., APeX SuperUser)

• Provides feedback related to staff performance

• Supports staff through orientation, training and oversight. Will attend monthly organization meetings/trainings to enhance SuperUser role within the practice.

• Is a team player who works closely with others and who is flexible in dealing with the changing priorities. Is 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.

Living Pride Standards

Service Excellence

1. Demonstrates service excellence by following the Everyday PRIDE Guide with the UCSF Medical Center standards and expectations for communication and behavior. These standards and expectations convey specific behavior associated with the Medical Center’s values: Professionalism, Respect, Integrity, Diversity and Excellence, and provide guidance on how we communicate with patients, visitors, faculty, staff, and students, virtually everyone, every day and with every encounter. These standards include, but are not limited to: personal appearance, acknowledging and greeting all patients and families, introductions using AIDET, managing up, service recovery, managing delays and expectations, phone standards, electronic communication, teamwork, cultural sensitivity and competency.

2. Uses effective communication skills with patients and staff; demonstrates proper telephone techniques and etiquette; acts as an escort to any patient or family member needing directions;