Insurance Pre-Auth Specialist I

				Overview:

Responsible for the completion of prior authorization, pre-certification, and notification for third party and government payers for all pre-scheduled elective inpatient,  Direct Admits, Emergency Room Admits and outpatient procedures. Utilizes a thorough working knowledge of insurance plans and benefit structures to obtain detailed benefit information and maximize plan benefits. Coordinates with third party payers, physicians, nursing staff and other health care providers, providing education/direction around the prior authorization/pre-certification process and requirements to ensure all government and other payer requirements are met for accurate organizational reimbursement.  Tracks, documents, and monitors prior authorization and pre-certification status.  Performs dynamic coding of outpatient services and urgent admits, correlating and documenting accurate procedural and diagnosis codes with physician orders. Responsible for providing notification of delays or denials of pre-authorization/pre-certification approvals to clinical staff within various service lines, and to the Managed Care, Utilization Management, and Patient Financial Services units.  May provide direction to patients on the appropriate appeal procedures for denials.  Understands insurance/payer policy language, benefits and authorization requirements upon admission, during hospital stay, and discharge, including concurrent reviews while patient is being treated.

Responsibilities:

* Identifies, reviews, and facilitates pre-authorization/pre-certification by Medicare, Medicaid, Commercial, and Managed Care payers, for all required services, to ensure provider eligibility requirements are met prior to receiving service. Utilizes appropriate systems/applications/portals and/or communicates with physician offices and third party payers as necessary.  

* Interprets a patient requisitions and accurately assigns correct diagnosis and procedural codes to visits in accordance with guidelines, maintaining accuracy of dynamic coding and sequencing of codes. Uses all available tools, including software, physicians offices, HIM coding staff etc. to ensure diagnosis codes assigned are correct and accurately represent patient signs, symptoms, and results, and ensures compliant billing and reimbursement.

* Participates in required continuing education and compliance training programs to maintain an understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques to support the effective application of ICD-10-CM and CPT coding guidelines to outpatient diagnoses and procedures. Staff will maintain up-to-date knowledge of best practices, standards, regulations, Joint Commission on Accreditation of Health Organizations (JCAHO), Centers for Medicare and Medicaid (CMS), Federal Intermediary (FI) and other related organizations.  

* Responsible for analyzing & evaluating patients' eligibility and benefits and reviewing reason for visit criteria to ensure all required documentation has been supplied by the ordering/referring physicians, and meets payer specific guidelines for each patient and health plan prior to patients admission for service to reduce claim denials, retrospective medical necessity reviews, and member benefit reductions.

* Maintains current payer reference manuals based on managed care, commercial, and governmental coverage weekly/monthly updates. Ensures all insurance requirements are met prior to patients' arrival, including, but not limited to, researching, identifying, and completing pre-authorization requests. Independently tracks status/outcomes of all requests.

* Maintain current knowledge/database of payers with additional prior authorization requirements for certain specialty services and/or expansions to care coordination programs/networks.

* Develops a thorough understanding of and a practical knowledge base of the proper use of all payor websites to accurately deliver appropriate information to patients regarding coverage and requirements for precertification of treatment, verification of benefits and self pay information. Assures pre-certification and pre authorization documentation are communicated by physicians offices and entered correctly in the hospital billing system.  Notifies appropriate parties when pre-certification problem/issues arises so that it can be dealt with in a timely fashion minimizing hospital losses as observed by Management, Patient Access Manager and as indicated by Patient Financial Services feedback.

* Provides administrative support to licensed health professionals to gather and enter pertinent information, supporting Medical Management functions for the Clinical Concurrent Review Team. Interacts with contracted providers and facilities to research issues, collect required information and/or communicate requirements or approval determinations.

* Provides coordination of benefits for primary, secondary, and tertiary coverage, establishing a uniform order of benefit determination under which plans pay claims, reducing duplication of benefits by permitting a reduction of benefits to be paid by plans that, pursuant to established rules, do not pay primary benefits, and providing greater efficiency in the processing of claims when patients are covered under more than one plan.

* Coordinates with MMC Patient Financial Services, Managed Care, Social Services, Case Management, Scheduling, and clinical departments to ensure consistent financial documentation across the enterprise, and an interdisciplinary approach to patient and organizational needs.

* Contacts third party payers and patients as necessary to facilitate timely payments or other required transactions that result in appropriate reimbursement. Maintains revenue cycle integrity.

* Effectively negotiates with patients and families to explain, collect, and record patient co-pays and/or deposits, within electronic payment system and Cerner registration module. Supports Patient Access Services POS (Point of Service) collection goals as defined by Revenue Cycle leadership and best practice benchmarks.

* Effectively triages, documents, and initiates referrals of patients to Medicaid vendor and/or for financial assistance. Maintains current knowledge of, and complies with the Illinois Fair Patient Billing Act, Illinois Uninsured Patient Discount Act, and established MMC procedures at all times.  Follows departmental productivity and quality control measures that support the operational goals and benchmarks.

* Analyzes reports containing rejected accounts from a variety of hospital sources, including Non-Patient Access registration departments, and resolves toward verification of patient benefit eligibility, and subsequent reimbursement from all possible payer sources, or determines suitability for financial assistance.

* Orients and cross-trains others within assigned area of responsibility as directed and defined by management. May assist other areas within the unit or department, as necessary, during times of special needs or staff absences. May be required to work night or weekend shifts.

* Understands the functionality of all computer systems related to job function. Assists in mentoring, training, and development of other Patient Access staff; serves as a resource to staff for questions and problem solving. Demonstrates an advanced understanding of third party payer requirements.

* Ensures compliance with all applicable HIPAA, Joint Commission, CDC, MMC, and state and federal statues, providing required associated literature to patients at all PAS access points. Educates patients regarding Advance Directives, Medicare D prescription coverage, and both Memorial and Illinois Department of Public Health grievance process as appropriate.

* Meets department and team benchmarks for productivity, accuracy, call abandonment, and point of service collections. Consistently meets or exceeds given goals for each area on a monthly basis.
			

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Memorial Health System