Highridge Medical | Patient Service Representative

Job Summary :

The Patient Services Representative’s (PSR) primary responsibility is to verify eligibility, confirm benefits and process pre-authorization, if required, for all non-invasive bone stimulation devices. PSRs coordinate with our sales force to collect patient data and inform them when a device is OK to apply. If a pre-authorization denial is received, the PSR will be required to review the denial and determine if an appeal / reconsideration is necessary (meets medical criteria, etc.), to proceed with obtaining authorization prior to billing. As part of this process, the PSR must acquire all necessary information, pursuing all avenues to complete the order process efficiently and effectively.

Principal Duties and Responsibilities :

• Examine all documentation received with new orders inclusive of patient demographics, clinical documentation, and other insurance related documents (i.e., authorizations, sales proposals, etc.) for accuracy and determination of insurance carrier medical criteria as it relates to non-invasive bone stimulation. Tasks carried out are specifically as follows :
• Demonstrate product knowledge in relation to the information being submitted.
• Review medical documentation and exhibit knowledge through accurate summarization in file, as it relates to medical necessity / insurance criteria for non-invasive bone stimulation.
• Demonstrate the ability to document all related job requirements in the FileNet database specifically as follows :
• Exhibit knowledge of workflow, including general knowledge of department workflow.
• All message documentation must be appropriate and reflect accuracy.
• Accurately identify the Sales Rep and prescribing physician for all orders being processed through accurate documentation and completion of corresponding FileNet fields.
• Accurately complete medical tab as supported by medical documentation.
• Accurately complete all tab requirements in relation to Sales commissions and payer requirements.
• FileNet Code knowledge as it relates to processing, workflow, and payer requirements (Insurance Type, Revenue Code, Policy Type, etc.).
• Accurately document Insurance benefits and authorization information.
• Summarize denial and appeals information.
• Contact the insurance carriers for verification of insurance eligibility and benefits and to initiate the pre-authorization process, if necessary. The following procedures are carried out, when determined to be applicable :
• Pursue retro-authorizations, when required.
• Identify, analyze and process appeals for denied pre-authorizations.
• Contact a Healthcare Policy & Payer Relations Director (RD) regarding contracting, criteria and pricing issues i.e., incorrect contract pricing, advise regarding non-contracted insurance carriers, constructing Letters of Agreement for non-contracted insurance carriers, etc.
• Act as the primary resource and liaison with the Sales Force and physician’s office to collect, communicate, and deliver medical information and necessary forms, ensuring all required information submitted is accurate.
• Handle and advise on all requested escalated orders as it relate to their affiliated BPO team.
• Manage & maintain all documentation required for audit site visit.
• Required to meet all department goals set forth by management.
• Act as Liaison between the Customer, the Sales Force, and the Insurance carrier / payer.
• Provide excellent customer support to all business contacts, including the Sales Force
• Participates in team member, including BPO team member, training.
• Other job functions as determined necessary and as assigned by management.

This is not an exhaustive list of duties or functions and may not necessarily comprise all of the "essential functions" for purposes of the ADA.

Expected Areas of Competence (i.e., knowledge, skills, and abilities)

Education / Experience Requirements

Travel Requirements

N / A

Work Location : Hybrid remote in Birmingham, AL 35243