JOB SUMMARY: Identifies internal processes/procedures required to facilitate managed care activities regarding pre-certification/utilization review, patient registration/insurance verification, billing, independently. Resolves claim payment and operational issues occurring with managed care contracts.
Coordinates payor specific operations meeting, both ad hoc and regularly scheduled with high volume payors.
Maintains database to track and manage operational issues by payor.
Identifies and discusses concerns or trends with Managed Care teams and payors to improve related operational process and resolve issues.
Ensures a permanent record of all payor meetings and follow-up documentation related to operational improvement activities.
Manages the single case agreement process.
The responsibilities listed are a general overview of the position and additional duties may be assigned.
CONTRACT INTERPRETATION (ADVANCED): - Understanding and making educated decisions based on the reasonable interpretation of a contact's intent and provisions.
HEALTH CARE OPERATIONS KNOWLEDGE (ADVANCED): - Awareness of the administrative, financial, legal, and quality improvement activities that are necessary to support the core functions of a health care organization, treatment and payment.
INSURANCE REGULATORY KNOWLEDGE (ADVANCED): - Demonstrates knowledge of the appropriate rules and regulations for insurance policies, claims, payment and coverage. Ability to interpret and explain rules and regulations that are ambiguous or unclear.
REGULATORY COMPLIANCE (INTERMEDIATE): - Demonstrates knowledge of the appropriate rules and regulations and apply them in difficult, stressful and complex situations. Able to interpret and explain rules and regulations that are ambiguous or unclear. Directs others in interpreting rules and regulations on the job and trains others in them.
COMMUNICATION (ADVANCED): - Clearly, effectively and respectfully communicates to employees or customers.
Organizational Impact: Independently delivers on objectives with understanding of how they impact the results of own area/team and other related teams.
Problem Solving/ Complexity of work: Utilizes multiple sources of data to analyze and resolve complex problems; may take a new perspective on existing solution.
Breadth of Knowledge: Has advanced knowledge within a professional area and basic knowledge across related areas.
Team Interaction: Acts as a go-to resource for colleagues with less experience; may lead small project teams.
Vanderbilt University Medical Center is home to Vanderbilt University Hospital, The Monroe Carell Jr. Children’s Hospital at Vanderbilt, the Vanderbilt Psychiatric Hospital and the Vanderbilt Stallworth Rehabilitation Hospital. These hospitals experienced more than 61,000 inpatient admissions during fiscal year 2015. Vanderbilt’s adult and pediatric clinics treated nearly 2 million patients during this same period. Vanderbilt University Hospital and the Monroe Carell Jr. Children’s Hospital at Vanderbilt are recognized again this year by U.S. News & World Report’s Best Hospitals as among the nation’s best with 18 nationally ranked specialties. Vanderbilt University Medical Center is world renowned because of the innovation, work ethic and collegiality of its employees. From our health care advances to our compassionate care, Vanderbilt owes its accomplishments and reputation to staff and faculty who bring skill and drive and innovation to the medical center day after day. World-leading academic departments and comprehensive centers of excellence pursue scientific discoveries and transformational educational and clinical advances across the entire spectrum of health and disease.As t...he largest employer in middle Tennessee, we welcome those who are interested in ongoing development in a caring, culturally sensitive and professional atmosphere. Most of us spend so much of our lives at work, we want to be part of maintaining a workplace in which people support one another and encourage reaching for excellence. Many high-achieving employees stay at Vanderbilt because of the professional growth they experience and because of their appreciation of Vanderbilt’s benefits, public events and discussions, athletic opportunities, beautiful setting and, above all, sense of community and purpose.Vanderbilt and its employees share a set of mutual expectations that have been created with productivity, legality, fairness and safety always in mind. We believe that our investment in training and compensating employees multiplies in value when we enable individuals to deliver their best performance for the benefit of us all.