Clinical Business Operations Representative

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Clinical Business Operations Representative 3

The University of Miami/UHealth department of Neurology has an exciting opportunity for a Full Time Clinical Business Operations Representative 3 to work Remote. The Clinical Business Operations Representative 3 facilitates the prompt resolution of problems related to pre- and post-care that arise in daily clinical operations. The incumbent performs general administrative and receptionist functions, to include answering incoming calls, efficient management of patients, and the acquisition of necessary patient care and records. The Clinical Business Operations Representative 3 assists patients in a courteous, efficient and professional manner and ensures adherence to divisional and departmental service standards.

• Assists the department in managing expectations surrounding pre- and post-patient care.

• Obtains or reviews all patient demographic information, insurance information, and referral numbers.

• Reviews clinical records for completeness including authorization, signatures, missing data, and other patient information.

• Answers multiple telephones for the department: triages incoming calls, responds to questions, directs calls, and documents messages in the appropriate software.

• Greets visitors and callers, handles their inquiries, and directs them to the appropriate employee according to their needs.

• Works cooperatively with fellow employees to solve problems and enhance the smooth and efficient flow of the practice.

• Provides coverage for responsibilities of co-workers when assigned or as need arises.

• Develops and promotes the use of effective methods of communicating with physicians, managers, peers, trainees, and staff on a regular basis.

• Maintains confidentiality of all information.

• Adheres to University and unit-level policies and procedures and safeguards University assets.

This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary.

Department Specific Functions

The Prior Authorization CBOR 3 manages complex authorization requests and appeals, works with insurance plans and clinical teams to resolve issues, helps prevent delays in patient care, and serves as a resource to staff by providing guidance, training, and support with challenging cases.

• Process Prior Authorizations: Process PAs for medications, specialty medications, procedures, imaging, and other services within the required timeframe.

• Review Requests: Make sure each request has the correct insurance, clinical information, medication details, and supporting documents.

• Submit PAs: Submit requests to the correct insurance plan and monitor them until a final decision is received.

• Follow Up: Follow up on pending PAs within the required timeframe to prevent delays in patient care.

• Resolve Issues: Identify and resolve missing information, insurance issues, documentation needs, and other problems that may delay the PA.

• Handle Denials and Appeals: Review denials and work with providers and clinical staff to obtain information needed for appeals or reconsiderations.

• Communicate With the Team: Keep providers, MAs, CBORs, and clinical staff updated on PA status, approvals, denials, appeals, and outstanding information.

• Verify Insurance: Confirm the patient's active insurance and make sure the PA is submitted to the correct plan.

• Update Insurance Information: When needed, work with the patient or appropriate staff to obtain updated insurance information.

• Document Accounts: Accurately document all PA activity, including submissions, follow-ups, calls, approvals, denials, appeals, and next steps.

• Manage Workload: Prioritize urgent requests while managing daily workload and meeting required turnaround times.

• Monitor Expirations: Track PA expiration dates and start renewals when needed to prevent gaps in treatment.

• Handle Complex Cases: Work independently on complex cases and escalate issues when additional assistance is needed.

• Improve Workflows: Identify common PA issues and suggest ways to improve workflow, reduce delays, and increase approvals.

• Support Team Members: Help other CBOR team members with questions, complex cases, and payer requirements.

• Stay Current: Keep up with insurance changes, payer requirements, PA criteria, and department processes.

• Prevent Patient Delays: Work each PA from start to finish and address issues promptly to help prevent delays in medications, treatments, procedures, or imaging.

Core Qualifications

• High School Diploma or equivalent/relevant experience, certification or license

• Minimum 2 years of relevant experience required

Knowledge, Skills and Abilities:

• Learning Agility: Ability to learn new procedures, technologies, and protocols, and adapt to changing priorities and work demands.

• Teamwork: Ability to work collaboratively with others and contribute to a team environment.

• Technical Proficiency: Skilled in using office software, technology, and relevant computer applications.

• Communication: Strong and clear written and verbal communication skills for interacting with colleagues and stakeholders.

Any relevant education, certifications and/or work experience may be considered.

The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more.

UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by the ground breaking research and medical education at the Miller School of Medicine. As an academic medical center, we are proud to serve South Florida, Latin America and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research and patient care. We're the challenge you've been looking for.

The University of Miami is an Equal Opportunity Employer. Applicants and employees are protected from discrimination based on certain categories protected by Federal law.

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