What are the responsibilities and job description for the Insurance Exception Specialist - FT - Days - Pre-Access Services position at Doctors Hospital At Renaissance?

DHR Health - US:TX:McAllen - Days

Summary:

MISSION STATEMENT:

Our Mission is to improve the well-being of those we serve with a commitment to excellence: every patient, every encounter, every time.

VISION:

Our Vision is to create a world-class health system to advance medicine and increase access for the communities we serve by empowering caregivers to heal through compassion, knowledge, innovation, integrated care and excellence.

POSITION SUMMARY:

This position will determine insurance eligibility, validation of authorization for Facility, financial status and eligibility for registration by reviewing insurance information via phone or on line verification, calling third party payers to obtain insurance benefits which include the effective dates of coverage, billing address, pre-existing condition clauses, in and out of network benefits and maximum coverage.

POSITION EDUCATION/ QUALIFICATIONS :

High School Diploma/ GED is required
Understand insurance benefits and medical terminology required
Knowledge of Microsoft Office suite, working knowledge of Excel required
Excellent Customer Service
Good written and verbal communication skills required.
Ability to read, write and speak English required

Ability to communicate clearly and concisely with all levels of management

· Previous healthcare experience (1-2 yrs.) is required, hospital/medical office experience preferred

JOB KNOWLEDGE/EXPERIENCE :

· Communicates clearly and concisely and is able to work effectively with other employees, patients and external parties

· Demonstrates proficiency in Microsoft Office applications, be able to type at least 35 WPM, and good working knowledge of Excel is required.

· Medical Terminology, ICD-9, ICD-10, Codes, CPT Codes, HCPCS code, Modifier knowledge preferred.

Able to perform basic mathematical calculations, balance and reconcile figures, punctuate properly and spell correctly.
Requires reasoning ability, good independent judgment and organizational skills.
Requires working with frequent interruptions.

· Must project a professional image

Responsibilities:

POSITION RESPONSIBILITES:

Promotes the facility mission, vision and values by effectively communicating them to others. Considers mission, vision and values in developing services, standards and practices.

Appropriately monitor and verify benefits all accounts daily on the Insurance Verifiers Application Program (Aeos) and for the next day’s to include 3 to 5 days out services.
Confirms billing address, pre-existing conditions, in and out of network benefits and maximum coverage.
Enter appropriate mnemonic notes that pertain to accounts.
Enter appropriate mnemonics notes to Paragon Management and Insurance Verifiers Application Program (Aeos)
Obtain proper insurance information and document into Paragon Management and Insurance Verifiers Application Program (Aeos),

· Reviews and confirms patient's financial information by obtaining the insurance carrier information, benefit information, policy number, group name, group number, and the effective date of coverage.

· Reviews and confirms patient's deductibles, co-pays, out of pocket and co-insurance with insurance carrier and on patients account and ORM Schedule.

Obtain life time max, paid through dates (premium paid),
Obtain policy exclusion, payable, billable, authorization number.
Obtain call reference number when calling an insurance by phone for denial purposes.
Obtain Medical Review and Pre-Determination (if required) with PCP Referral Authorization.
Obtain out Of Network Authorization, and Gap Authorization (Other Hospital within 25 mile).
Obtain two authorization In Network and Out of Network from Workers companion for Travelers Insurance, Framers and Liberty Mutual.
Obtain authorization on all NB with secondary insurance (to avoid denials)
Obtains date of injury, compensable bodily injury, adjuster’s name, onset of illness and claim number, for worker’s compensation claims.
Obtained approval dates, CPT Codes, validate approval is for DHR.
Asking insurance if procedure is considered cosmetic, does Implant require authorization?
Confirm claim address, payor ID, group number, policy number, pre-existing conditions, in and out of network benefits and maximum coverage.
Ability to read and understand insurance card and select correct I-Plan.

· Ability to reference ICD-9-CM/ ICD-10-CM, CPT from doctor’s order to insurance carrier for eligibility and coverage of procedure.

· Ability to identify Procedure Codes for In Patient vs Out Patient.

· Ability to identify a Screening procedure vs a Diagnostic procedure.

· Ability to have excellent communication with MD Office Staff and MD with questions regarding Doctors orders, Procedure Codes and diagnosis.

· Ability to determine timely filing deadline for all insurance carriers.

· Ability to identify the appropriate coordination of benefits for insurance carrier.

· Utilizes phone or on-line verification systems, i.e. TMHP, RELAY, My Ability, and Availity, etc., for insurance eligibility and benefits.

· Determines financial status and refers patient for financial screening as appropriate.

· Ensures referral/pre-authorization/pre-certification requirements have been met.

Obtains pre-certification approval as needed.
Verify and assign appropriate insurance plan code, as needed.
Reviews physician order for appropriate patient status (Inpatient/Outpatient) before verifying coverage for procedure.
Prepare short registration by obtaining patient demographic information, type of insurance, diagnosis and procedure requested as needed.
Ability to understand the difference between an Ambulatory Facility vs Out-Patient Facility setting.
Review all incoming email and work properly to avoid patient delays.
Required to run the ORM Schedule.
Required to have knowledge on working Unbilled Report.
Required to have knowledge on working denials that pertain to no Pre-Certification.
Required to contact MD Office staff with Late Add On accounts (with no authorization on file).
Required knowledge on sending emails to Utilization Reviewer department when clinical are required from insurance.
Required knowledge on sending emails to Financial Counselor when patient has met Spell of Illness.
Required to work all failed Notification via emailed by Business System Specialist department.
Required to work all Status Changes/Upgrades being email by PIC Admission Specialist & UR department.
Required to send an Email at the end of the day to Registration Management with pending authorizations for the next day.
Ability to work emails within 15 minutes sent by all areas from DHR.
Utilizes tickler, when requesting additional information from other co-workers or departments.
Communicates information about scheduled case procedure to various departments and personnel involved.

· Works closely with peers to ensure all procedures regarding patient’s accounts are completed in a thorough and timely manner.

· Accurately performs basic mathematical calculations, balance and reconcile figures, punctuate properly and spell correctly.

· Document clearly and concisely all patient benefit information on accounts through the patient accounting system (Pre-cert screen, account notes section of Paragon and ORM schedule).

· Demonstrates proficiency of personal computers and Microsoft Office applications and other software as required.

Maintains a contact list for each physician office.

· Ensures patient confidentiality requirements are met in accordance with HIPAA/PHI policies and procedures.

· Other duties as assigned.

LINES OF REPSONSIBILITES :

(Chain-of-command)

Pre-Access Supervisor

→ 2.

Pre-Access Manager

→ 3.

Director

Other information:

CUSTOMER SERVICE:

Provide excellent customer service to all DHR customers. All employees are required to attend the DHR C.A.R.E.S program which outlines the Customer Service Principals including: Commitment, Accountability, Respect, Excellence and Service.

AGE SPECIFIC :

Employees must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served in his/her assigned unit. The individual must demonstrate knowledge of principles of growth and development over the life span and possess the ability to assess data reflective of the patient’s status and interpret the appropriate information needed to identify each patient’s requirement relative to his or her age.

AMERICANS WITH DISABILITIES ACT: (ADA) :

A. Essential Duties : Indicated by bold print within performance standards, preceding individual numbered criteria.

The following table provides physical requirements that will be associated with, but not limited to, this position:

Light/moderate lifting up to 20 lbs, from the floor to shoulder height.

Yes

Kneeling

Yes

Must be able to assist other employees with lifting more than 20 lbs.

Yes

Walking

Yes

Light/moderate carrying up to 20 lbs.

Yes

Standing/Squatting

Yes

Straight pulling

Yes

Sitting

Yes

Pulling hand over hand

Yes

Pushing

Yes

Repeated bending

Yes

Stooping/Bending

Yes

Reaching above shoulder

Yes

Climbing Stairs

Yes

Simple grasping

Yes

Climbing Ladders

Dual simultaneous grasping

Yes

Depth Perceptions needed

Yes

Ability to see

Yes

Identify Colors

Yes

Operating office equipment

Yes

Twisting

Yes

Operating mechanical equipment

Yes

Crawling

Ability to read and write

Yes

Ability to Count

Yes

Ability to hear verbal communication without aid

Yes

Operating Personal Vehicle

Yes

Ability to comprehend written/verbal communication

Yes

Other: Ability to deal with stress

Yes

OSHA Category

III

B. Working Conditions: The individual spends over 95% of his/her time in an air-conditioned environment with varying exposures to noise. There is protection from weather conditions but not necessarily from temperature changes. The position does have low exposure to malodorous, infectious body fluids from patients and some minimal exposure to noxious smells from cleansing agents.

C. Occupational Exposure: This position has minimal to no exposure to blood, body fluids, or tissues and is an OSHA Category III (although situations can be imagined or hypothesized under which anyone, anywhere, might encounter potential exposure to body fluids). Person who performs these duties are not called upon as part of their employment to perform or assist in emergency medical care or first aid or to be potentially exposed in some other way.

D. Aptitudes: HIGH 1 2 3 4 5 6 LOW

Intelligence: General learning ability: The ability to “catch on” or understand instructions and underlying principles. Ability to reason and make judgments. 3

Verbal: Ability to understand meanings of words and ideas associated with them, and to use them effectively. To comprehend language, to understand relationships between words, and to understand meanings of whole sentences and paragraphs. To present information or ideas clearly. 3

Numerical: Ability to perform arithmetic operations quickly and accurately. 2

Spatial: Ability to comprehend forms in space and understands relationships of plane and solid objects. Frequently described as the ability to “visualize” objects or two or three dimensions, or to think visually of geometric forms. 2

Form Perception: Ability to perceive pertinent details and objects or in pictorial or graphic material to make visual comparisons and discriminations and see slight differences in shapes and shadings of figures and widths and lengths of lines. 3

Clerical Perception: Ability to receive pertinent details and verbal or tabular material. To observe differences in copy, to proofread words and numbers, and to avoid perceptual errors in arithmetic computation. 2

Motor Coordination: Ability to coordinate eyes and hands to fingers rapidly and accurately in making precise movements with speed. Ability to make a movement response accurately and quickly. 3

Finger Dexterity: Ability to move hands easily and skillfully. To work with fingers in placing and turning motions. 3

Manual Dexterity: Ability to move hands easily and skillfully. To work with hands in placing and turning motions. 3

Eye-Hand-Foot Coordination: Ability to move the hand and foot coordinately with each other in accordance with visual stimuli. 3

Color Discrimination: Ability to perceive and respond to similarities or differences in colors, shapes, or other values of the same or different color. To identify a particular color, or to recognize harmonious or contrasting color combinations, or to match color adequately. 3

I have read and reviewed my job description with my supervisor or designee and I understand the job I am expected to perform.

If applicable ____________ certification will be completed within _________ time frame of hire/transfer date.

Employee Signature: ________________________________ Date: ____________________

Transfer/Hire Date Effective: ________________________. CUSTOMER SERVICE: