Lead Payor Specialist

Quick Facts

• Hybrid schedule: first 6 months onsite, then hybrid

Description

Lead the Payor Specialist team to ensure timely initial and continued stay authorizations for acute care inpatients. Coordinate and communicate accurate clinical information with payors, review escalated cases for appropriateness and accuracy, and coach staff on authorization, payor specifications, and denial coordination. Partner with internal teams to support clinical quality utilization goals and manage complex payor issues.

Responsibilities

• Lead the work of Payor Specialists and serve as a resource for Best Practices
• Train and orient Payor Specialists; maintain training materials and records
• Review escalated cases for appropriateness and accuracy; further escalate authorization challenges as needed
• Coach Payor Specialists and Quality Utilization Specialists on payor specifications and obtainment of authorization; support denial coordination
• Help resolve operational and workflow issues; foster a professional, positive team environment
• Participate in quality improvement activities and recommend process improvements
• Collaborate with Managed Care, Patient Access, Social Work, Financial Clearance, and external stakeholders
• Provide first-line support for patient, technical, and workflow problems within scope
• Coordinate and supervise staffing coverage; adjust assignments for absences or increased volume
• Escalate extraordinary issues to Quality Utilization leadership; assist with data preparation and presentations
• As needed, perform Payor Specialist duties: communicate clinical information for pre-authorization and pre-certification; track payor information requests; coordinate onsite payor review; document and communicate denials/peer review and out-of-network status

Requirements

• Bachelor’s degree
• Minimum 5 years of healthcare/related experience
• Conversant with medical terminology
• Expertise and knowledge of third-party payor, Medicare/Medicaid guidelines
• Advanced computer skills (word processing and spreadsheets)
• Experience preparing training tools and/or workflow design
• Computer and database management skills to manage QU department electronic systems, including Careport and Epic

Benefits

• Comprehensive benefits supporting physical, emotional, and financial well-being and protection for unexpected life events
• See benefits details and eligibility by employment classification at https://jobs.nm.org/benefits