General Summary

Under general supervision, responsible for processing the patient,insuranceand financial clearance aspects for both scheduled and non-scheduled appointments, including, validation of insurance and benefits, routine and complex pre-certification, prior authorizations, and scheduling/pre-registration.Responsible for triaging routine financial clearance work.

Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classifications. These are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

• Processes administrative and financial components of financial clearance including, validation of insurance/benefits, medical necessity validation, routine and complex pre-certification, prior-authorization, scheduling/pre-registration, patientbenefitand cost estimates, as well as pre-collection ofout of pocketcost share and financialassistancereferrals.

• Initiates and tracks referrals, insuranceverificationand authorizations for all encounters.

• Utilizes third party payer websites, real-time eligibility tools, and telephone to retrieve coverage eligibility, authorizationrequirementsand benefit information, including copays and deductibles.

• Works directly withphysiciansoffice staff to obtain clinical data needed toacquireauthorization fromcarrier.

• Inputs information online orcallscarrier tosubmitrequestfor authorization; provides clinicalback upfor test and documents approval or pending status.

• Identifiesissues and problems with referral/insurance verification processes; analyzes current processes and recommends solutions and improvements.

• Reviews andfollowsup on pending authorization requests.

• Coordinates and schedules services with providers and clinics.

• Researchesdelays in service and discrepancies of orders.

• Assistsmanagement with denial issues by providing supporting data.

• Pre-registers patients to obtain demographic and insurance information for registration, insurance verification, authorization,referralsand bill processing.

• Develops andmaintainsa working rapport with inter-departmental personnel including ancillary departments, physician offices, and financial services.

• Assists Medicare patients with the Lifetime Reserve process where applicable.

• Reviews previous day admissions to ensure payer notification upon observation or admission.

• Must be willing to travel between facilities as needed (applies to specific UMMS Facilities).

• Performs other duties as assigned.

III. Educationand Experience

• High School Diploma or equivalent isrequired.
• Minimum two years of experience in healthcare revenue cycle, medical office, hospital, patientaccessor related experience.
• Experience in healthcare registration, scheduling, insurancereferraland authorization processes preferred.

IV. Knowledge,Skillsand Abilities

• Knowledge of medical and insurance terminology.
• Knowledge of medical insurance plans, especiallymanagecare plans.
• Ability to understand, interpret, evaluate, and resolve basic customer service issues.
• Excellent verbal communication, telephone etiquette, interviewing, and interpersonal skills to interact with peers, superiors, patients, and members of the healthcare team and external agencies.
• Intermediate analytical skills to resolve problems and provide patient and referring physicians with information andassistancewith financial clearance issues.
• Basic working knowledge of UB04 and Explanation of Benefits (EOB).
• Some knowledge of medical terminology and CPT/ICD-10 coding.
• Demonstrate dependability, criticalthinking, andcreativityand problem-solving abilities.
• Knowledge of registration and admitting services, general hospital administrative practices, operational principles, The Joint Commission, federal, state, and legal statutes preferred.
• Knowledge of the Patient Access and hospital billing operations of Epic preferred.