Insurance Verifier, Ambulatory Patient Access

DHR Health - US:TX:Edinburg - 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 and financial status 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, patient financial responsibility, referral and authorization requirements, in and out of network benefits and maximum coverage.

POSITION EDUCATION/ QUALIFICATIONS :

• High School Diploma/ GED is required

• Comprehensive understanding of insurance benefits, referral requirements, reimbursement and medical terminology

• Excellent customer service skills, required

• Ability to work with geriatric patients in a high volume fast paced practice

• Computer skills required with knowledge of Microsoft Office suite, and the internet

• Excellent written and verbal communication skills required

• Bilingual – English/Spanish – preferred

JOB KNOWLEDGE/EXPERIENCE :

• Minimum of 2 years of insurance verification/referral experience is preferred, physician office experience preferred

• Communicates clearly and concisely via phone and is able to work effectively with other employees, providers, patients and external parties

• Medical Terminology, ICD and CPT Codes, HCPCS code, 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:

• Serves as a daily resource for all questions from providers, management and staff

• Appropriately monitors and verify benefits on all accounts requiring referrals and authorizations on a daily basis

• Assists billing staff with researching accounts with discrepancies in payments, rejections and/or denials to ensure appropriate payer reimbursement

• Handles calls and questions from patients, physicians, ins. carriers and ancillary providers with questions concerning referrals and authorizations

• Confirms billing address, in and out of network benefits and maximum coverage for services being provided

• Uses knowledge of ins. carrier requirements to give appropriate information to each carrier, ex. MCR vs. MCD when requesting benefit information.

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

• Ability to reference ICD-9-CM/ ICD-10-CM, CPT from doctor’s order to insurance carrier

• Reviews and confirms patient's deductibles, co-pays, and co-insurance on patients account

• Ability to identify the appropriate coordination of benefits for insurance carrier

• Utilizes phone and on-line verification systems, i.e. TMHP, Availity, Customer Kiosk and insurance carrier portals for eligibility, benefits and authorization submission

• Ensures referral/pre-authorization/pre-certification requirements have been met in a timely manner

• Verifies that the appropriate insurance carrier is assigned to the account and updates/corrects insurance information if applicable.

• Reviews physician order for appropriate patient status (Inpatient/Outpatient) before verifying coverage for procedure

• Enter appropriate notes in the patient accounting system by documenting clearly and concisely all patient benefit information

• Communicates information about scheduled case, procedure, referral, authorizations to office personnel involved, as needed

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

• Uses knowledge of procedures to review and coordinate the correct diagnosis with procedures for each patient referral received

• Receives faxed authorizations from insurance carriers and MD offices, hospitals and other specialists to ensure continuation of care to other services for clinic patients

• Calls with patient on the line to advice if the PCP on file is different than the PCP the patient is scheduled with, example HMO plans.

• Arranges for peer to peer reviews for insurance coverage/authorization as needed

• Provides medical records release of information for patients as needed

• Demonstrates proficiency of computer and practice software as required

• Ensures patient confidentiality requirements are met in accordance with policies and procedures

• Report any/all equipment failures to Supervisor and Administrator

• Other duties as assigned

LINES OF REPSONSIBILITES :

(Chain-of-command)

1. Director Ambulatory Patient Access 2. VP of Revenue Cycle 3. Chief Ambulatory Officer

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:

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: ________________________.