Patient Access Insurance Specialist - Beacon Health System

Reports to the Registration Manager or the Emergency Care Center (ECC) Manager. Follows established Beacon policies and procedures to verify insurance coverage to ensure necessary procedures and hospitalizations are covered by an individual's provider. The Insurance Verification Authorization Specialist will assure authorization is obtained for all procedures and diagnostic testing to services being rendered. The Authorization Specialist will also initiate the authorization for direct admissions, emergency admissions, and emergency procedures. They will work closely with medical staff, clinical staff, referring clinics, Centralized Scheduling, Surgery Scheduling, Social Services, and Utilization Review departments. They will be responsible for communication with insurance carriers and/or providers for purposes of obtaining approval for services requiring authorization, pre-certification, and prior approval for admissions to Beacon or Epworth Center by using web based tools, other electronic means where possible, or by telephoning and faxing when necessary. Coordinating those visits with the correct paperwork and insurance verification, along with accurate documentation in the patient's medical record is essential. They will answer high volume of incoming phone calls as well as making high volume of outbound phone calls, with constant communication to the Utilization Review, Social Services, and Surgery Scheduling departments. Performs other clerical duties as necessary. MISSION, VALUES and SERVICE GOALS

• MISSION: We deliver outstanding care, inspire health, and connect with heart.
• VALUES: Trust. Respect. Integrity. Compassion.
• SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.

Verify demographic and insurance information is complete and accurate by:

• Updating the system after validation of the new patient's financial information.
• Obtains accurate insurance information and communicates with patient and/or physician office staff.
• Using the Pathways Healthcare Scheduling (PHS) or Cerner databases to locate/retrieve scheduled patients for admission/registration input into STAR.
• Generating PHS and SurgiNet reports to facilitate verification of scheduled procedures.
• Explaining about the possible need to pre-certify with the patient's insurance carrier in order to ensure maximum coverage to the limits of the insured's insurance policy.
• Verifying and documenting insurance coverage via online eligibility systems, internet resources or via telephone.
• Validating medical necessity via the MCA Compliance Checker where applicable.
• Auditing the MSP (Medicare Secondary Payor) questionnaire by verifying that all fields are completed.
• Referring the patient to the Financial Counselors or Eligibility Specialists if they are unable to secure satisfactory payment arrangements and have a self-pay balance of $500 or more. Also assisting in obtaining additional patient information, copies of insurance card(s) and church information.
• Obtaining all required signatures for the 'consent to treat' and assignment of insurance benefits forms.

Coordinates both the Verification of Benefits and Authorization/Pre-Certification/documentation (PA) processes for patients by:

• Verifying insurance coverage by calling the insurance company or using online eligibility systems to determine the patient's benefits under the insurance plan.
• Obtaining VOB information from the insurance company, such as: co-payment, co-insurance, deductible, the amount of the deductible that has been met year-to-date, family deductible, maximum out-of-pocket limit and rehabilitation benefits.
• Run insurance eligibility software, make needed phone calls to insurance companies, fax authorization requests.
• Documenting all VOB information in the computer system.
• Obtaining pre-certification information from the insurance company's pre-certification unit (i.e., whether pre-certification is required, if the ordering physician has completed it, etc.).
• Securing authorization on all patients for ancillary, surgical, and out-patient testing/procedures/admissions.
• When the ordering physician has not completed the pre-certification, work with physician office and surgery scheduling or centralized scheduling to reschedule any procedures that are not fully authorized.
• Runs & Ensures medical necessity is complete with proper CPT and ICD-10 codes as physician order specifies.
• When the ordering physician has completed the pre-certification, documenting the authorization and releasing the account.
• Initiate authorizations for direct admissions, emergency admissions, and emergency procedures.
• Ensures all authorization obtained from referring facilities are accurate and complete.
• Identify out of network insurance plans and follow the out of network policy.
• Prepare Indiana Medicaid/HIP Universal PA form for Utilization Review.
• Keeps accurate worklists and documentation.
• Uploading demographic information to payors as requested.

Coordinates other patient services and performs clerical duties by:

• Preparing patient statistics (i.e., percentages) regarding completed demographic information as requested by the Director and/or Manager.
• Preparing the reports which are necessary for verification of benefits; also working with the information on the bill edit report.
• Releasing patient accounts for proper and timely claims filing.
• Calculating co-payments and coinsurance for services rendered (either verbally or in writing) per the insurance companies' request.
• Processing verification of benefits and authorizations in an efficient manner.
• Answering the telephone and communicating information in an appropriate manner according to approved Beacon standards and departmental policies and procedures.

Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by:

• Providing world class service at all times.
• Assisting the department to meet or exceed its quality assurance goals.
• Acknowledge, file, and send messages keeping an ongoing line of communication with Utilization Review, Surgery Scheduling, Social Services.
• Works closely with the physician office staff to ensure that pre-cert/pre-authorization numbers are obtained & entered in the registration system.
• Acting as a representative of Memorial Hospital of South Bend/Memorial Health System and striving to make a good first impression.
• Striving to accurately process an optimal number of verifications during one's shift.
• Communicating with the Manager (or Director) regarding any concerns or problems.
• Maintaining records, reports and files as required by departmental policies and procedures.
• Performing time of service collections effectively by achieving assigned collections goals and maintaining strong patient relations.
• Completing other job-related duties as assigned.

ORGANIZATIONAL RESPONSIBILITIES

Associate complies with the following organizational requirements:

• Attends and participates in department meetings and is accountable for all information shared.
• Completes mandatory education, annual competencies and department specific education within established timeframes.
• Completes annual employee health requirements within established timeframes.
• Maintains license/certification, registration in good standing throughout fiscal year.
• Direct patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
• Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
• Adheres to regulatory agency requirements, survey process and compliance.
• Complies with established organization and department policies.
• Available to work overtime in addition to working additional or other shifts and schedules when required.

Commitment to Beacon's six-point Operating System, referred to as The Beacon Way:

• Leverage innovation everywhere.
• Cultivate human talent.
• Embrace performance improvement.
• Build greatness through accountability.
• Use information to improve and advance.
• Communicate clearly and continuously.

Education and Experience

• The knowledge, skills and abilities as indicated below are normally acquired through the successful completion of a high school diploma (or equivalent). A minimum of two years of experience in a hospital or physician practice business office is required. Excellent time management, organizational skills, research/analytical skills, negotiation, communication (written and verbal), and interpersonal skills required. A medical terminology course must be successfully completed prior to employment. Associate's Degree preferred. Medical prior authorizations or claims experience in a managed care setting and CHAA certification are highly preferred.

Knowledge & Skills

• Requires basic office and keyboarding skills (with the ability to type a minimum of 40 wpm) and the ability to use designated reference materials and office equipment (i.e., computer, printer, fax machine, calculator, etc.).
• Requires effective telephone skills (for example, to accurately take and relay information about patients, physician orders and referrals).
• Demonstrates proficient computer skills (i.e., data entry, word processing and spreadsheets). Requires the ability to use multiple databases (such as Pathways Healthcare Scheduling, RelayHealth, Cerner and MCA Compliance Checker).
• Requires a complete understanding of time of service collections. Specifically, must understand why it is necessary and must be able to effectively communicate this to Beacon's patient community as necessary.
• Requires extensive knowledge of medical terminology, private insurance coverage (and managed care), insurance networks, ICD10, and CPT codes.
• Demonstrates the interpersonal skills necessary to interact effectively with patients from various backgrounds in a professional, enthusiastic, courteous, friendly, caring and sincere manner. Also demonstrates the ability to maintain effective working relationships with other departments, physicians and their office staff.
• Demonstrates the verbal communication skills needed to communicate in a clear and effective manner when communicating with insurance companies, other departments, and physician offices.
• Good listening skills are required. Sensitivity to individuals who do not speak English as their first language is expected.
• Requires the ability to strictly follow Beacon's policy on confidentiality. Also requires the ability to be aware of the need to lower one's voice in certain situations.
• Requires ability to utilize good judgment and maintain one's composure in stressful situations.
• Requires the basic math skills needed to calculate patient's insurance benefits such as deductible, coinsurance, and out of pocket.

Working Conditions

• Works in an office environment. Also may work in patient care areas with possible exposure to bio-hazards.
• Requires a flexible work schedule (including evenings, nights and weekends) that meets the needs of the Department.
• Must be effective in a quality-focused, multi-priority environment that frequently deals with stressful situations and important deadlines and schedules.

Physical Demands

• Requires the physical ability and stamina (i.e., to walk moderate distances, climb stairs, lift up to 15 pounds, reach, bend, stoop, twist, etc.) to perform the essential functions of the position.

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