Patient Precertification Associate

General Summary of Position
Provides assistance to patients in the department. Coordinates all the functions and activities related to patient pre-certification/authorization including but not limited to: accurate and complete patient registration in the approved organization electronic scheduling and billing systems and on-site insurance verification.

Primary Duties and Responsibilities

• Contributes to the achievement of established department goals and objectives and adheres to entity hospital and/or department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations.
• Verifies eligibility and conformance to the department and departmental managed care requirements and contracts. References the MedStar Managed Care Matrix and online Handbook as necessary.
• Obtains insurance referrals and preauthorizations. Submits all referral information to necessary providers as appropriate. Assists with preauthorizations of hospital admisions procedures medications and medical equipment.
• Maintains ongoing communication with insurance companies to determine eligibility of benefits deductible status and to obtain precertification for office-based and other procedures. Educates and informs patients and families regarding verification status and issues related to deductibles co-payments and balances. Responds to hospital staff and/or patient inquiries regarding referrals authorizations and scheduling in an efficient manner.
• Searches the Enterprise Access Directory (EAD) to establish if the patient is new or existing. Follows guidelines to avoid duplicate medical record assignment; Obtains and/or verifies complete demographic and insurance information from the patient. Accurately enters complete demographics insurance information and Financial Status Classification (FSC) / Hospital Patient Accounting Plan Code assignment into the approved organization's electronic scheduling and billing systems.
• Resolves all outstanding alerts on pending appointments within 48 hours of the scheduled appointment to minimally include: Missing Referral Missing Pre-certification/Authorization Self Pay Accounts Eligibility Verification Missing Demographic/Insurance Information MedStar and/or department specific requirements. Enters all relevant data linking to the appropriate appointment/visit and ensures all required data elements are captured.
• Ensures all relevant data is entered into the Open Referrals Module links data to the appropriate appointment/visit and enters the required data elements to ensure that accurate billing information is submitted to the appropriate insurance carrier. Obtains any missing pre-certification or authorization numbers and enters into the appropriate field in the Appointment Data Form (ADF). Establishes if the appointment needs to be rescheduled due to a missing Referral or Authorization number.
• Works with departmental supervisor and/or clinician to determine medical necessity and if the appointment can be rescheduled. If appropriate notifies the patient that the appointment needs to be rescheduled due to missing Referral/Pre-certification/Authorization.
• Reviews patient accounts with self-pay status. Confirms that patients understand the need to make payment on outstanding balances. Reviews rejected accounts to provide updated information to Physicians' Unified Billing Service (PUBS) and relays appropriate information regarding denied claims to patients when necessary. Where appropriate and within department guidelines ensures collection of pre-payments/deposits due from the patient prior to service for elective cases and prior to the procedure for add-on cases.
• Reviews encounter forms to ensure appropriate data is being collected according to department guidelines. Performs coding and error resolution. Where appropriate reconciles operative log report to ensure all procedure fees have been submitted to PUBS. Reconciles Admissions Discharges and Transfers (ADT) reports to ensure all inpatient visits have been submitted to PUBS.
• Completes daily deposit by completing Official Receipts and Journal Vouchers for processing payments. Maintains deposit logs and records. Researches and resolves any deposit discrepancies. At the end of each day or session batches encounter forms prepares Batch Entry Form and Batch Control Log to be sent to PUBS.
• Compiles and runs the Missing Charge Report each month and assists Administrator with reconciliation of missing charges. Performs quality audits as requested. Serves as liaison to PUBS and Patient Financial Clearance Unit (PFCU). Reviews rejection reports ensures that corrective action is taken on all denied charges and that all charge sheets are resubmitted to PUBS for processing. Provides cross-coverage to Front Desk Check-in / Check-out position. Assists with payment and billing questions.
• Obtains basic clinical information from patients/callers to determine the appropriate appointment type and provider to which the appointment should be booked. Identifies patient's insurance ascertains department contract participation status (Par vs. Non-Par) and communicates contract participation status to patient. Determines referral requirements creates Referral in the approved organization electronic scheduling and billing system and links to appointment or updates ADF with Authorization / Pre-Certification number as appropriate.
• Schedules patient procedures and follow-up appointments using the approved organization electronic scheduling and billing system entering all required data elements as dictated by the entity and departmental policies and procedures. Communicates referral requirements patient's financial responsibility and other pre-appointment information including necessary procedure/examination preparations according to departmental policies and procedures.
• Answers incoming calls for practice and provides information regarding services referrals etc. Using standard forms or Electronic Health Record (EHR) system records messages from patients referring physicians pharmacies and other clinical areas. Communicates with physicians and nurses. Prints and distributes provider schedules to clinical team/management/administration as appropriate.
• Accesses patient's medical record / electronic health record (MR/EHR) to complete proper patient documentation in the health record or to view needed information in the patient chart as necessary. Adheres to current workflows or processes developed within the department or specific Practice. Scans and indexes documents using correct naming conventions into patient EHR.
• Maintains and utilizes all office equipment such as computers fax machines telephones etc. Maintains competency in all electronic systems required for job functions. Communicates building and facility issues or concerns to the appropriate housekeeping staff for resolution. Reports computer malfunctions software issues and/or problems to the Help Desk or appropriate staff.
• Observes Joint Commission standards Patient Safety initiatives Patient Rights and Health Insurance Portability and Accountability Act (HIPAA) Privacy standards. Follows care documentation and cleanliness standards in the performance of job duties.
• Completes in-services and education on a timely basis. Focuses on patient safety during performance of duties and improves or makes corrections when safety issues arise and notifies department manager as required. Interacts with other team members both in the Practice and in other departments in an appropriate and proactive way to benefit the patient.
• Participates in meetings and on committees and represents the department and hospital in community outreach efforts. Participates in multi-disciplinary quality and service improvement teams.

Minimal Qualifications
Education

• Associate's degree required
• One year of relevant education may be substituted for one year of required work experience.

Experience

• 3-4 years Experience in a medical/clinical office working knowledge of IDX / GE centricity business preferred and
• Previous experience with computerized scheduling and registration systems. Previous experience with an electronic health record system desire especially GE centricity clinical or Aria required
• One year of relevant professional-level work experience may be substituted for one year of required education.

Licenses and Certifications

• No special certification registration or licensure required

Knowledge Skills and Abilities

• Excellent interpersonal communication and customer service skills and good telephone etiquette.
• Knowledge of medical terminology.
• Effective oral and written communication skills.
• Ability to deal effectively and professionally with a variety of different individuals.
• Ability to perform in a high-pressure environment.
• Ability to organize and prioritize work.