Location: Kent Campus Hospital

Status: Full Time 80 Hours

Shift: Day/ Evening

General Summary:

This is a multi-faceted role within Patient Access and outpatient departments. The Specialist is responsible for obtaining and verifying the accuracy of insurance authorizations, the precise recording of diagnosis codes, timely charge posting to support accurate billing, point of service collections, and account reimbursement resolution. Resolves failed medical necessity concerns and billing issues with clinical staff. Identifies patients without adequate insurance coverage and coordinates financial counseling. Performs scheduling and/or place orders for patient testing. Provides oversight, training, cross-coverage and maintains proficiency in the duties of scheduling and front office functions, including registrations necessary for the efficient day-to-day operation of the facility. Screens patients for financial assistance, government, and charitable programs to ensure hospital bill resolution. The Patient Accounts Specialist serves as liaison between customers, insurance carries and the department while maintaining compliance with applicable regulatory requirements.

Responsibilities:

1. Insurance Authorization for Services/Treatment a) Verify referring Physician authorization of services and ensures all diagnosis codes are accurate and appropriate prior to service delivery; working closely and collaboratively with physician offices. b) Verify pre-authorization or obtains authorization from insurance carrier. Works pro-actively to ensure insurance authorization is obtained prior to rendering services or treatment; or recommends postponement of services if requirements are not met. c) Review insurance coverage information with patient, and obtain Advanced Beneficiary Notice (ABN) from patient if services are not covered. d) Work with clinical staff to assure appropriate charge capture and authorizations are received when services/treatment are altered. Coding
2. Coding a) Ensure all diagnosis codes and charges are accurate according to official CPT and ICD-9/ICD-10 CMS guidelines, meeting all applicable State and Federal laws and regulations. b) Work actively with providers and clinical staff in problem resolution for issues related to diagnosis coding and compliance.
3. Charge Capture/Billing a) Accurately post all technical and professional charges on a daily basis in appropriate hospital information system prior to export (i.e., EMR system, Horizon, etc.) b) Verify charge entries within 24 hours of posting, using defined audit processes and available reports. Follow up all fall out reports (i.e., Failed Bill Report from Star). Collaborate with appropriate clinical staff and manager to resolve. Perform additional charge audits as requested. c) Collaborate with supervisor/manager and Finance Department to resolve account issues as requested within billing cycle and in appropriate hospital information system (i.e., Denial and Appeals Module in Star).
4. Denial Management a) Review and appropriately follow up on accounts in denial or appeal status; (i.e., Denials and Appeals module in Star; or alternative software. b) Research denied claims, incorrect payments. Processes appeals in a timely manner. c) Ensure all write-offs, denials and appeals are tracked appropriately.
5. Co-pays and Collections a) Review insurance coverage for all patients, then determine and notify patient of payment responsibility for co-pays. b) Accurately collect co-pays as required by Bayhealth and the patient’s insurance at the time of service (point-of-service collections). c) Collaborate with supervisor/manager and Finance Department in the Payment Recovery Program. d) Responsible for balancing cash and accounts; process patient credit refunds
6. Registration Oversight a) Provide oversight and assistance to Registrars, providing training and mentoring as needed. b) Assist Registrars in more complicated and complex functions c) Assist in onboarding of new Registrars; under guidance of supervisor/manager
7. Provide cross-support for front office positions a) Patient flow – maintain efficient patient flow in the registration and check-in process. Accurately complete reception duties in accordance with policies. b) Registration – accurately complete patient registration process c) Insurance Verification – obtain copies of insurance card when registering patient d) Scheduling – accurately schedules new patients and follow up appointments, following procedures and protocols. Assist patients with referral needs in obtaining additional appointments with specialists, and insurance approval authorization for additional visits.
8. All other duties as assigned within the scope and range of job responsibilities

Required Education, Credential(s) and Experience:

• Education: High School Diploma or GED
  ;
  ;
• Credential(s): None Required
  ;
• Experience: Required: 2 years of medical office/ insurance clerical experience; prior experience with CPT and ICD-9/ICD-10 coding Preferred: 3 years of medical office/ insurance experience, with administrative billing functions, health information systems. Specialized training in accounting principles, medical coding, medical terminology

Preferred Education, Credential(s) and Experience:

• Education: Associate Degree
  Health Care
• Credential(s): Certified Professional Coder
  Certified Billing and Coding Specialist
  Certified Healthcare Access Associate
  Certified Coding Specialist
• Experience:

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