- Purpose of Job
- Serves at a resource to the Pre-Access staff members. Monitors work queues and triages day-to-day system or resources to accommodate work queues and add on cases. Trains and facilitates onboarding of new staff members and develops training and testing required for onboarding new services to the Pre-Access department. Assists leadership with quality audits and development of educational materials. Obtains prior authorizations for designated procedures.
- Job Requirements
- High School Diploma or General Educational Development (G.E.D.) required.
- Associates degree in Health Information Management, or other relevant business related preferred.
- Minimum of 5 year experience in clinic, billing or pre-authorization required.
- Certified Professional Coder (CPC) certification is preferred.
- Knowledge and understanding of medical terminology, documentation, progress notes, and other medical reports/results required.
- Knowledge of treatment guidelines, medical necessity and reimbursement criteria required.
- Extensive knowledge of payer guidelines and tools.
- Excellent written and oral communication skills required.
- Ability to communicate requirements to physicians, nurses, and clinical managers and gain their cooperation in the authorization/pre-certification process.
- 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.
- Strong interpersonal and customer service skills with the ability to collaborate with coworkers, providers, and patients to ensure the highest satisfaction levels and outcomes.
- Skill in problem solving in informal and formal settings.
- Strong computer skills (proficient in Word, Excel, and Outlook).
- Physical Requirements
- Weight Demands
- Light Work - Exerting up to 20 pounds of force.
- Not necessary for the position (0%):
- Occasionally Performed (1%-33%):
- Distinguish colors
- Frequently Performed (34%-66%):
- Repetitive Motions
- Constantly Performed (67%-100%):
- 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)
- Mechanical moving parts/vibrations
- Essential Job Functions
- Essential Functions I
Ensures prior authorization obtained for designated scheduled cases to support denial prevention.
- Monitors preaccess daily report and allocates team resources as needed to meet department goals.
- Utilizes the preaccess report to identify trends in authorization delays based on date scheduled and date authorization obtained.
- Monitors and assigns add on same day next day procedure.
- Maintains consistent rotation of same day encounters.
- Completes prior authorizations for same day appointments, as needed.
Monitors quality assurance.
- Audits completed cases for accuracy, required scripting, and appropriate follow up with payer/providers, correct procedure codes, and payer loaded.
- Follows up with team members if additional activities/information is required to support preaccess and denial prevention.
- Proactively works with clinic, providers and coding to educate and reduce future denials.
- Communicates with leadership the results of quality audit trends.
Functions as the primary day to day resource for Preaccess Specialist staff.
- Acts as the department resources for preaccess processes related to day to day operations.
- Triages day to day system issues to the appropriate departments or contacts.
- Communicates information obtained from payer representatives to revenue cycle training (RCT).
Functions as the primary trainer for preaccess staff members.
- Leads both group and one-on-one training for team members.
- Trains new staff members in preaccess process (verification, cost estimation, and prior authorizations).
- Follows designated training checklist providing feedback to leadership regarding team member's training status, ongoing training objectives, further development, and effectiveness of training and individual growth.
- Collaborates with leadership to develop training plans, workflow processes, and department reference materials.
- Coordinates educational opportunities for team members. (Example - webinars, payer updates, etc.).
- Communicates payer changes to staff members and updates reference materials.
Functions as the primary trainer for onboarding new services and/or work tools.
- Collaborates with leadership to evaluate system resources required for onboarding new services.
- Assists in developing actions plans for testing and onboarding of new services.
- Collaborates with leadership to develop training materials and reference guides for new tools, functions, directions, print screens, etc.
- Trains preaccess team members on new workflow process or tools; i.e. use of new tools, new scripting or scripting changes, methods of denial prevention, etc.
- Reports and delays or barriers for implementation.
Facilitates customer service and provider relations.
- Triages and processes customer service requests as appropriate.
- Collaborates with provider's office regarding obtaining information required for preaccess or obtaining medical necessity approval from payer when preaccess staff has made every attempt to resolve.
- Notifies leadership if additional communication/collaboration is needed with provider offices.
- Alerts Patient Financial Counselor (PFC) team members of delay in cost estimations process, errors, or price discrepancy trends.
Performs the duties of a preaccess staff member.
- Works cases as needed to support team goals.
- Verifies patient demographics, insurance plans/player source, eligibility and benefits.
- Obtains certification/authorization according to payer guidelines.
- Verifies medical necessity and creates cost estimates for designated procedures.
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.