Center for Health Care Strategies

• The AVP, Access & Engagement Center is a highly visible and influential leader responsible for shaping and executing the enterprise strategy of the Access & Engagement Center in close partnership with senior leaders. • Collaborates with leadership to define strategic priorities, operating models, and long-term vision for patient access and engagement, while owning end-to-end performance outcomes for the organization. • Provides executive oversight across all Access & Engagement Center functions, ensuring alignment between strategy, infrastructure, operations, and frontline execution to deliver high-quality, efficient, and patient-centered access to care. • Partners across clinical, operational, digital, financial, and enterprise teams to drive integrated solutions, manage risk, and adapt quickly to evolving organizational needs. • Reinforces Nemours core values of continuous improvement, respect for people, and consistent patient and employee experience among Access & Engagement Center associates.

• Authorization Coordination: Ability to request and obtain preauthorization for assigned specialties and ability to cover for other workflows including workqueue items. This will involve submitting required documentation, following up on requests to ensuring timely approvals. • Ensure request for authorizations and notifications are worked timely and handled in accordance with departmental policy and payer requirements. Following all documentation requirements. • Insurance Verification: Verify patients’ insurance coverage, eligibility, demographics, benefits and financial responsibility to determine if prior authorization is required for specific medical procedures or treatments; additionally any predetermination requirements to ensure proper payment for service to support collection accuracy & efforts. • Policy Knowledge: Stay up to date with insurance policies, guidelines, and procedures related to authorization and reimbursement processes. This includes understanding specific requirements for different insurance companies and their medical coverage policies. • Properly process appointment or appt add-ons, changes to previously scheduled services, date changes, and or impactful service changes in need of immediate review. • Follow administrative review process if a service does not have an insurance authorization outside of the department’s standard timeframe. • Communication: Communicate with patients, their families, and healthcare professionals to provide updates on the status of authorization requests, address questions or concerns, and ensure a smooth process for all parties involved. • Promptly review clinical documentation for necessary information to submit to the payer along with authorization request. • Documentation and Record-Keeping: Maintain accurate and detailed records of authorization requests, approvals, denials, and any related correspondence. This includes documenting patient information, insurance details, and the authorization process itself. • Collaboration: Collaborates with healthcare providers, physicians, and clinical staff, additionally the Central Business Office, Financial Services, Transport, Patient Cost Estimation, Managed Care, Utilization Review, dedicated Authorization Departments, and other departments that have impact on obtaining authorizations and/or reimbursement. • Problem-solving: Identify and address any barriers or challenges that may arise during the authorization process. This could involve working with insurance companies to resolve denials, appealing decisions, or finding alternative solutions for patients’ medical needs. • The Specialist will attend and participate in daily departmental huddles to report on payer issues, barriers affecting workflows, and specific issues that could result in a non-reimbursable or canceled service. • The Specialist must be organized, work effectively in a virtual team environment, can problem solve, and seek assistance when needed. • Build and maintain professional, cooperative relationships with contacts from specialty departments. Consistently demonstrates excellent, empathetic, and knowledgeable customer service skills to internal and external customers. • Compliance: Adhere to relevant laws, regulations, and privacy guidelines when handling patient information and insurance-related documentation. Ensure all authorization processes are conducted ethically and in accordance with organizational policies.

• Ensure 100% charge capture by reviewing physician dictated notes and operative reports and properly code all services performed utilizing appropriate CPT, ICD-10-CM codes and modifiers. • Daily review of EPIC Charge Review Work queues is essential. • Monitor and report on accounts receivable issues related to payer compliance and/or billing processes. • Act as a resource to providers, office staff, administration and the Central Business Office. • Participation in coding training and education is also required. • Maintain yearly certification as a Certified Professional Coder is required with the American Academy of Professional Coders.

• Develop and maintain data solutions using Microsoft Fabric, including Lakehouse, SQL Analytics Endpoint, Spark, and OneLake. • Build and enhance data pipelines for ingestion, transformation, and curation of enterprise data. • Contribute to CI/CD implementation for Fabric assets using GitHub, including notebooks, SQL scripts, and deployment workflows. • Support modernization efforts for workloads currently dependent on the on‑prem EDW. • Assist in addressing technical debt resulting from the Clarity Oracle to SQL Server migration. • Collaborate with senior engineers and architects to follow established data engineering standards and best practices. • Support testing, validation, and operational monitoring of Fabric workloads. • Participate in production support and issue resolution as needed to ensure platform reliability.

• Following departmental policies to collect data for the verification and evaluation of medical staff credentials. • Obtain primary source verification of professional credentials for applicants to the medical staff and practices in accordance with departmental policy. • Collect data and prepare medical staff reappointment files for presentations to various committees and physicians. • Maintain the confidentiality of highly sensitive practitioner-specific information. • Maintain accurate, complete and timely information in the credentials software system. • Assist in the maintenance of systems to track expiring documents. • Assist in the preparation and updating of all required documents. • Use discretion in preparing reports and releasing such reports containing highly sensitive practitioner-specific information. • Respond to queries regarding status of pending applications. • Other duties as assigned.

• Ability to comprehend medical record documentation to assign codes for each active session, in multiple specialties. (i.e. Codes assigned by provider are evaluated and modified with the __approval__ of the provider) • Codes a minimum of 60-100 sessions per shift. The number of lines per session varies, therefore, “Coding Required” sessions are completed daily. • Works collaboratively in a team setting with providers, allied health staff, business office staff throughout the enterprise to achieve accurately coded 1500 claims. • Analyzes high-risk encounters for accurate charge capture and makes recommendation before transferring to second level review work queues. • Facilitates modifications to clinical documentation to ensure that information captured supports the level of service rendered, with attention towards chronic conditions, hierarchical condition categories (HCC) and risk adjustment factors (RAF). • Understands complexity of billing requirements and incorporates payer specific trends into day-to-day reviews to reduce “take backs” associated with un-clear, nonspecific, or un-substantiated care rendered. • Crossover coding is expected to help in any and all professional sessions (as assigned) using written reliable methods which identifies standard work requirements by session type. • Communicates with providers directly for clarification or gaps in documentation prior to submitting the session to assign the code(s) which fit services rendered. • Maintains production and accuracy objectives (i.e. metrics) identified annually.

• Provide ongoing Quality Assurance for CBO Business Service associates • Conduct quality reviews and report evaluations to the team supervisor • Provide ongoing development and maintenance of training materials • Act as a resource and answer questions to all team members • Assist team in reviewing and processing daily work • Work closely with all teams under Business Services for efficient workflows • Responsible for obtaining and maintaining policies and procedures • Compile information and prepare reports to monitor team goals and results • Test, implement, and train associates on materials related to Epic Upgrade • Identify, analyze and report any credit trends to management team • Cross-trained in workflows of other teams for reporting and training purposes • Assist respective team and other teams with daily duties as assigned

• Ability to comprehend medical record documentation to accurately assign codes for both concurrent and discharged accounts across multiple specialties. • Meets minimum requirements for production and quality monthly. • Requires a working knowledge of code sequencing for grouper-related payers with attention to detail to avoid rework and waste with charge capture assessment component. • Requires understanding and application of M.E.A.T. criteria (i.e., monitoring, evaluation, assessment, treatment) using ICD 10 CM transaction data set to capture diagnoses. • Analyzes high-risk encounters for accurate and/or missing charges gaps prior to encounter completion (i.e., missing charges from anesthesia, surgery) when manual charge capture occurs. • Understand complexity of billing requirements and incorporates payer specific trends into day-to-day reviews to reduce “take backs” associated with unclear, or unsubstantiated care rendered. (i.e., varying modifier assignment for EAPG vs. Non-EAPG payer specificity) • Requires excellent coding knowledge of ICD 10 CM, CPT 4, and modifier application, with expectations to maintain certification (i.e., CCS, CPC, RHIT, or RHIA) and apply ICD 10 CM Coding Guidelines specific to both inpatient and outpatient encounters. • Facilitate modifications to clinical documentation through query interaction to ensure that the information captured supports the level of service rendered, with attention towards chronic conditions, hierarchical condition categories (HCC), and risk adjustment factors (RAF). • Demonstrates an excellent working knowledge of hospital information systems to retrieve data specific information (i.e., order diagnosis, patient type) within a complicated filing schema including non-hospital data (i.e., Media Tab, Office Visits etc)

• Analyze and classify documents within the document management system. • Index documents into the patient’s electronic medical record (EMR) as digital formats, for ease of storage, retrieval, and use. • Maintain a 99% accuracy rate and 95% productivity rate. • Create encounters in the EMR system as per policy and procedure as needed to consistently locate patient documentation. • Demonstrate a working knowledge of the HIM policies and reliable methods governing the verification process. • Validating the authenticity of legal documents. • Utilizing advanced technology to eliminate printing and redundancy of documents. • Apply critical thinking skills, exhibit strong independent judgment, and research skills. Able to assess complex problems, overcome challenges, and adapt to changes. • Additional miscellaneous duties and responsibilities, as may be assigned from time to time by employee’s supervisor.

• Ensure timely notification and request for authorization/referrals is handled in accordance with departmental policy and payor requirements. • Maintain confidentiality and verify patient demographics, insurance eligibility, benefits, and financial responsibility. • Ability to request/obtain authorizations/referrals for assigned specialties and cover for most specialties. • Communicate effectively, timely and professionally in writing and verbally. • Contact and interview families in person or by phone to obtain necessary information and assist with insurance issues. • Clearly document all communications and contacts with payors and families in standardized documentation requirements. • Consistently demonstrate excellent, empathetic and knowledgeable customer service skills. • Adhere to all State and Federal Regulations including, but not limited to: EMTALA, HIPAA, and the Joint Commission. • Ability to review workflows and suggest improvements in specialty areas. • Ability to work independently, prioritize workload, and assist other associates. • Build and maintain professional relationships with all departments that impact obtaining authorizations. • Prepare estimates for scheduled services, interpreting patient’s benefits for accuracy. • Work with partner hospitals for claim submission and registration accuracy.