Patient Access Specialist PTI

Job Title: Patient Access Specialist

Job Code: PTACSPEC

Department: Patient Access

Division: Finance

Salary Level: Non-Exempt 4

Reports to: Patient Access Manager/Member Services Manager

Last Revised: February 2022

Primary Function

Greets all patients, families, visitors and coworkers in a prompt, polite, and helpful manner

and directs them, as necessary. Determine, verify, and explain CIHA eligibility to patients,

check-in or registering patients for their visits, and answering all incoming calls to the

facility.

Answers the EBCI Tribal Option Member/Provider Services1800 number and effectively

direct callers to the appropriate party, provide warm transfers when necessary and

appropriate and provide external referral information to assist members/providers to get

their needs met. Responsible for conducting patient interviews, distributing, and obtaining

signatures for paperwork, entering pertinent information including demographic and

insurance, verifying insurance eligibility, determining, verifying, and explaining services,

and collecting co-pays if applicable. Receives complaint/grievance calls in a welcoming

and supportive manner. Logs complaint/grievance information into the customer service

platform and elevates complaint/grievance calls as appropriate to Tribal Option

Management staff.

Job Duties

Patient Relations Duties

• Interviews patients to obtain pertinent patient registration information, i.e.,
  
  

demographic and insurance information and authorization to enable the Business

Office to bill for health care services provided from all alternate resources, including

the non-beneficiary service.

• Verifies all information collected for accuracy. Verifies insurance coverage through the
  
  

health plan and determines applicable co-payment and collects co-payment if

applicable.

• Creates and completes new charts in the BPRM Patient Registration System after
  
  

researching and verifying that there is not an existing chart for the patient. This will

include inpatient, outpatient, emergencies and after hour patients, dental patients, and

mental health patients.

• Obtains and verifies the health records in the BPRM Patient Registration System for
  
  

Medicaid, Medicare, and private/commercial insurance eligibility information for all

patients seen prior to all clinic visits.

• Obtains signature for file on all required forms for alternate resource and contract health
  
  

services prior to patients being seen in the clinics for billing purposes and/or contract

health services eligibility.

• Makes corrections as necessary to improve the Patient Registration System. Updates
  
  

PRC eligibility with proper documentation.

• Collects third party recipient health cards, obtains photocopies of the card and explains
  
  

the program to the beneficiaries, i.e., why Medicare, Medicaid and/or Private

Insurances will be billed for services they receive at the Cherokee Indian Hospital.

• Interviews patients to obtain information to initiate a new health record and/or
  
  

communicate to Medical Records to reactivate a retire/stored record. Enters all

information into the BPRM Patient Registration System and prints appropriate forms.

• Upon direction initiates all admitting forms to complete the admission with current
  
  

patient data, including BPRM Patient Registration System. Initiates patient

identification bands for admission.

• Completes Medicare Secondary Payer Questionnaire for Medicare beneficiaries and
  
  

files appropriately.

• Transcribes all new insurance information into the BPRM system in all the appropriate
  
  

fields. Verifies if patient has NC BCBS, NC Medicaid, or other private insurance.

• Calls pending verification patients before appointments to remind of documentation to
  
  

bring in i.e., driver’s license, enrollment care, proofs of residency, etc.

• Obtains patient signature for Service Agreements, Notice of Privacy Practices, etc.,
  
  

scans forms signed by patients into VISTA.

• Documents MVA/WC in BPRM/RPMS by obtaining signatures for appropriate forms,
  
  

giving clinic appropriate documents, obtaining police reports, entering appropriate

benefit for coverage in order for the Business Office to bill correctly and alerts clinic

staff.

• Documents all changes, updates on the notes page with date, and initials.
• Collects fees and co-pays from non-beneficiaries, prints register and credit card report
  
  

at end of shift, maintains petty cash and turns all receipts and reports into Finance.

Member/Patient Service Duties

• Answers eligibility questions for new patients or Members and lets the individual know
  
  

What The Benefits Are Based Upon Eligibility Status.

• Answers the Member/Provider 1800 Tribal Option line consistently and provides
  
  

information, warm transfers, and referral information as appropriate and necessary to

ensure caller’s needs are met. Member/Provider toll free number is to be answered

during the CIHA Business Day defined as Monday-Friday 8:00-4:30, except for posted

CIHA holidays.

• Follow approved Service Line scripts to ensure correct, consistent information is
  
  

provided to the Member/Provider.

• Log every call received into the customer service platform to ensure appropriate
  
  

documentation and resolution of all calls. This is the foundation of data that is required

to be provided to the state as part of the PCCM Tribal Option Contract.

• Promptly returns calls to individuals or entities if a request for a call back is made after
  
  

hours, the return phone call shall be made the following CIHA business Day during

normal hours of operation. Triages the message and notifies applicable business owner

based upon the type of information requested.

• Answers telephone switchboard for all CIHA facilities and directs calls to appropriate
  
  

staff member/department.

• Maintains an updated list of all departments, personnel, and extensions to assure proper
  
  

transfer of calls.

• Greets visitors when necessary, answers questions, or directs them to the appropriate
  
  

person or department.

• Maintains the vendor/visitor sign in and provides vendor/visitors with Visitor badge.
• Keeps a log of after hour call-in referrals and turns into PRC during regular business
  
  

hours.

• Determines the need for interpreter or translation services and accesses the necessary
  
  

platform(s) to ensure the individual receives communication in the manner necessary

to provide effective communication with the individual. This includes but not limited

to calls to/from Members with limited English Proficiency, as well as Members with

communication impairments, including those with hearing, deaf-blind callers to

include TTY, captioned phones, and amplified phones.

Documenting Member/Provider Grievances

• Document all Provider or Member grievances/complaints received via the service lines
  
  

or in person.

• Provide complete and appropriate documentation of all complaints/grievances within
  
  

the customer service platform.

• Elevate complaint/grievances to the appropriate Tribal Option Manager per
  
  

policy/protocol.

Other Duties as Assigned

• Performs other duties as requested from the Patient Registration Manager, or Member
  
  

Services Manager

Education/Experience/Minimum Qualifications

• High school diploma/GED is required.
• An Associate’s Degree in Business and/or Accounting, or a related field, or the
  
  

Equivalent Combination Of Training, Education, And Experience Is Preferred.

• Previous data entry experience or clerical experience with customer contact of two
  
  

years is required.

• Three to six months in the job would be necessary to become proficient in most phases
  
  

of the work.

Job Knowledge

• Ability to establish and maintain effective working relationships with members of the CIHA
  
  

team, individuals and their families, and a variety of governmental and private resources and

organizations in the community.

• Ability to express ideas clearly and concisely and to plan and execute work effectively.
• Must be able to read, research, and interpret computer data or customer service platform
  
  

related to patient/member interviews and eligibility searches. Basic knowledge of

eligibility requirements of the Cherokee Indian Hospital and the EBCI Tribal Option

including resources in the local community and neighboring counties.

• Requires the ability to answer and transfer calls using the phone system and utilize
  
  

computer, calculator, and related office equipment.

• Requires knowledge of various software packages: i.e. Microsoft Excel, Word,
  
  

Outlook, and the Customer Service Platform and ability to enter information or data

into the applicable software package. Documentation must be in “real time”.

• Knowledge of interview techniques and experience in applying various policies and
  
  

procedures in the performance of assigned duties. Must be able to maintain specified

records, files, and logs of the department.

• Must have excellent communication skills, both written and verbal.
• Requires the ability to work independently or as a member of a team. Valid NCDL
  
  

required. Knowledge and ability to work within multiple systems simultaneously.

• Knowledge of complaint/grievance workflows call transfer matrix as well as Tribal
  
  

Option information and how to locate Tribal Option information to assist

Members/Providers.

• Knowledge of the population served and about the Cherokee culture preferred.
  
  

Complexity of Duties

This position is responsible for assisting individuals connect to the right service or entity within

CIHA/EBCI Tribal Option or the ability to refer to applicable entity based upon eligibility

criteria. As such, the position requires the ability to listen and filter relevant information in

order to refer accordingly without causing confusion or disruption to the communication event.

Duties require the application of judgment and problem-solving skills in order to be effective.

At times may be dealing with individuals who are concerned about access to services,

dissatisfied, agitated or emotional.

• The position requires ability to operate multiple software packages, documenting
  
  

information in the appropriate software platform. In addition, the position must possess

phone skills, including familiarity with complex or multi-line phone systems.

Responsibility for Accuracy

Typically, this position is the initial point of contact patients checking in for services

rendered at CIHA and also for calls received via the EBCI Tribal Option Member/Provider

Service Line. As such, accuracy is of upmost importance to ensure that eligibility data is

accurate and information shared is accurate. Responsible for accuracy of demographic,

eligibility and insurance information obtained and entered into BPRM/RPMS. Errors can

be detected through interview techniques and subsequent interviews with patients or

Members. Work can be verified or checked by the immediate supervisor, or other hospital

staff. Incoming or outgoing calls can be monitored to ensure accuracy and adherence to

approved scripts. Logged calls and complaints/grievances must be accurate and meet state

reporting requirements.

NC Medicaid requires that calls from Members and Providers be answered in a certain

manner, adhering to approved scripts. In addition, documentation must be gathered in real

time, addressing all required fields so that reporting may be conducted and submitted in

accordance to the DHHS Tribal Option Contract. NC Medicaid or other regulatory

agencies may conduct “mystery shopping”, audits or reviews to ensure compliance to EBCI

Tribal Option requirements.

Contact with Others

This position has primary contact with patients/members and providers for the purpose of

conducting interviews, answering the Tribal Option Member/Provider line, accepting and

documenting grievances/complaints and the patient/member registration process.

Secondary contacts include, but not limited to staff within CIHA such as medical records

staff, pharmacy staff, billing office staff, and contract health staff and other external entities

visiting CIHA or calling in.

All contacts require tact, courtesy, and professional decorum. Utmost sensitivity and

confidentiality is required when dealing with patients and families. Consistently demonstrates

superior customer service to patients/members, providers, and customers. Ensures

excellent customer service is provided to all patients/members, providers, and customers

by seeking out opportunities to be of service.

Confidential Data

All health information and data is considered highly confidential and strict adherence to all

applicable policies is required. The position has access to highly confidential patient/member

medical and personal information. The Privacy Act of 1974 mandates that the incumbent

shall maintain complete confidentiality of all administrative, medical, and all other

pertinent information that comes to his/her attention or knowledge. The Act carries both

civil and criminal penalties for unlawful disclosure of records. Violations of such

confidentiality shall be cause for adverse action. The individual must always adhere to all

CIHA/EBCI Tribal Option confidentiality and security policies and procedures.

Mental/Visual/Physical

The level of concentration varies with tasks, with close attention to detail required while

entering data and verifying accuracy of information. Duties of this position require the

employee to be mobile, reach with hands and arms, speak, and hear. Must have visual

acuity. Position is subject to frequent interruptions, requiring varied responses. Must be

able to handle multiple projects simultaneously, work independently, and meet deadlines

and time frames. May occasionally move more than 15 pounds.

Resourcefulness and Initiative

Follows well defined procedures with initiative and judgment required maintaining

accuracy and complete tasks in a timely fashion.

Environment

Majority of work is performed within the hospital environment requiring interaction

throughout the hospital. Occasional travel is required. Immunizations are required of all

employees.

Customer Service

Consistently demonstrates superior customer service skills to patients/customers by

demonstrating characteristics that align with CIHA’s guiding principles and core values.

Ensure excellent customer service is provided to all patients/customers by seeking out

opportunities to be of service.