- Purpose of Job
- Responsible for obtaining financial clearance for designated procedures. Verifies patient demographics, insurance plans/payer source, eligibility and benefits. Obtains pre-certification/authorization according to payer guidelines, verifies medical necessity and creates estimates for designated procedures which define patient responsibility.
- Job Requirements
- High School Diploma or General Educational Development (G.E.D) required
- Minimum of one year previous experience with health insurance industry, precertification, payer verification, billing or claims processing or denial / appeals experience required.
- Previous customer service, medical terminology and working knowledge of computer functionality to include Windows applications and Internet familiarity required.
- Requires the ability to provide transportation to other campus locations within a reasonable timeframe.
- Must understand medical documentation, progress notes, and other medical reports/results.
- Knowledge of treatment guidelines, medical necessity and reimbursement criteria preferred.
- Excellent written and oral communication skills required.
- Must have the ability to communicate requirements to physicians, nurses, and clinical managers and gain their cooperation in the auth/pre-cert process.
- Must process the ability to handle intense, multiple priorities successfully and adapt quickly with an understanding of the reimbursement failure/consequences if the job is not performed correctly.
- Problem solving skills in an informal/formal setting necessary.
- Strong interpersonal and customer service skills necessary.
- Strong computer skills (proficient in Word, Excel and Outlook).
- Physical Requirements
- Weight Demands
- Light Work - Exerting up to 20 pounds of force.
- Not neccessary for the position (0%):
- Occasionally Performed (1%-33%):
- Distinguish colors
- Frequently Performed (34%-66%):
- Constantly Performed (67%-100%):
- Repetitive Motions
- Not Related:
- Chemical agents (Toxic, Corrosive, Flammable, Latex)
- Biological agents (primary air born and blood born viruses) (Jobs with Patient contact) (BBF)
- Physical hazards (noise, temperature, lighting, wet floors, outdoors, sharps) (more than ordinary office environment)
- Explosives (pressurized gas)
- Electrical Shock/Static
- Radiation Alpha, Beta and Gamma (particles such as X-ray, Cat Scan, Gamma Knife, etc)
- Radiation Non-Ionizing (Ultraviolet, visible light, infrared and microwaves that causes injuries to tissue or thermal or photochemical means)
- Essential Job Functions
- Essential Functions I
Manages the denial process by securing pre-service financial clearance for designated scheduled diagnostic procedures.
- Maintains focus on mitigating pre-service denials.
- Communicates to business office all pertinent information regarding potential for denial of payment and/or levels of care.
Obtains pre-service financial clearance (authorization/precertification) for specified diagnostic procedures from payer source.
- Verifies the payer source, if not previously completed:
- Verifies patient demographics, payer source from work queue by utilizing websites, previously collected registration information or by making phone calls to insurance companies, patients, employers, etc.
- Creates cost estimation for designated procedures.
- Utilizes electronic tools to create estimates for designated procedures.
- Documents patient responsibility in electronic registration conversation to ensure information is readily available to other healthcare professionals (i.e. Patient Financial Counselors and Registration Specialists).
- Obtains precertification/authorization from payer source.
- Collects, existing clinical data within the various Cerner applications or obtains the information from the ordering provider by asking appropriate questions to satisfy various precert/authorization guidelines.
- The information is relayed to the insurance carrier via their website, a telephone call and/or fax after verification of eligibility has been performed. (This requires extensive knowledge and functionality of various website applications and the continual monitoring of a request's progress until obtained or denied.)
- Performs medical necessity checking for designated payers/procedures to determine in advance if the procedure or treatment is reasonable and necessary for the patient's diagnosis or illness.
- Documents medical necessity checking outcome.
- Generates the waiver/ABN if medical necessity checking does not meet payer criteria.
- Scans the waiver for patient's signature into registration conversation making the waiver is readily available for other healthcare workers.
- Documents instructions to other health care professionals regarding the need for signatures if waiver needs to be signed at registration.
Communicates with the provider office staff and patient, if appropriate, with specific information when the pre-certification/authorization or medical necessity is denied or will be delayed by the payer.
- Uses clear, polite and professional communication skills to include ‘Please' & ‘Thank You'.
- Obtains additional documentation to support financial clearance or medical necessity, as appropriate.
- Communicate actions needed, as appropriate, with MD office when financial clearance or medical necessity for the procedure was denied by the payer. (i.e. Patient responsibility, conveying to patient the need for a waiver, cancelling or rescheduling case, etc.).
Documents/Communicates with high degree of accuracy and clarity regarding the process, completion and outcome of verification, pre-certification/authorization and medical necessity.
- Use clear communication skills and professional excellence in documentation that can be referenced by other healthcare professionals within the organization.
- Documents into the registration system the progression of all activity associated to the request to include , action taken, reference numbers for pre-authorization, patient responsibility and directions to additional healthcare professionals i.e. the failure of meeting medical necessity with waiver documents needing to be signed, date, time and initials.
- Assimilates and organizes supporting paper documents and forwards to Health Information for scanning into the electronic medical record (EMR), as appropriate.
Maintains reference materials, uses work time productively (ie: does not abuse personal telephone privileges, personal internet use and keeps unnecessary conversation to a minimum) demonstrates the ability to organize time and sets appropriate priorities.
- Maintains/updates reference material to accomplish daily duties.
- Sets priorities that benefit the department and organizes time to complete the tasks.
- Can quickly adapt when new processes are introduced and/or existing processes are modified.
Promotes office efficiency by exemplifying the team work philosophy.
- Shares critical information pertaining to newly discovered information or management updates.
- Willingness to help co-workers to accomplish department mission.
Reports significant incidents related to patients or department activities and seek supervision when needed.
- Recognizes problems and informs management.
- Willing to take action when issues occur.
- Able to provide necessary information to other departments.
Essential Functions II
Participates in mandatory in-services and/or CE programs as mandated by policies and procedures/external agencies and as directed by management.
Follows and understands the mission, vision, core values, Employee Standards of Behavior and company policies/procedures.
Other duties as assigned.
- Willing to adjust work schedule if necessary.
Methodist Health System
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