Clinical Coordinator - Patient Engagement Center

Clinical Triage/Authorization Nurse

The Clinical Triage/Authorization Nurse will assist the Patient Engagement Center Pre-Service as the first point of contact for the Primary Care Pod (ADULT and Pediatrics) for assessment of need of sick visit and trigger words identified through the patient/parent telephone call, through a pre-defined triage assessment provided by the respective Clinics. Will work collaboratively with Clinic Nursing Leadership to ensure patient requests and inquiries are managed timely and triage trigger words expeditiously. Will ensure payers are prepared to reimburse for scheduled services in accordance with the payer-provider contract and works diligently toward the identification, mitigation, and prevention of clinical denials. In addition to contacting payers and providers via phone, portal or fax, to secure authorizations, this position will use their clinical expertise by reviewing medical necessity, responding to authorization concerns and/or reconciling coverage-related issues.

Will assist the Pre-Service Team, primarily the Primary Care (adult and pediatric) PODS to triage clinical complaints, trigger symptoms and clinical inquiries appropriately and expeditiously.

Work collaboratively with Clinic Nursing Leadership to ensure patient is contacted expeditiously same day for trigger word/symptom follow up.

Uses benefits and order information on file to initiate and secure pre-authorization in advance of service date; excellent knowledge of third-party payer authorization portals.

Communicates with physicians, patients, payers, Patient Engagement Center Representatives and Authorization Specialists to obtain missing demographic information, insurance or clinical information needed to secure authorization for scheduled services.

Documents all payer communications thoroughly and communicated payer decisions in a timely manner. Manages Medical Necessity as service necessitates and identifies patients needing Medicare Advance Beneficiary Notices (ABNs) Assist with the maintenance of Authorization Requirements by Payer database to ensure accuracy by Payer and Product line.

Responsible for review of services being rendered to ensure the appropriate setting of care has been assigned by the physician's office

Ability to organize work with multiple steps to ensure no scheduling or authorization needs are missed.

Thank you for your interest in Albany Med Health System! Albany Med Health System is an equal opportunity employer.

This role may require access to information considered sensitive to Albany Med Health System, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that:

Access to information is based on a "need to know" and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Health System policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.