Insurance verifier job description

The Insurance Verifier provides a timely and accurate insurance verification; obtaining current eligibility, benefit coverage and authorizations to provide the necessary data to ensure reimbursement in a timely manner. This position identifies reimbursement resources for patient care and maximizing the effort to capture it. Identifies patient responsibilities, insurance reimbursement and other 3rd party reimbursement sources. Working knowledge of contracts with the ability to interpret per diem rates, case rates, stop loss, resulting in timely and accurate reimbursement. Performs outpatient pre-registration function, maintains effective working relations with coworkers, case management, outside companies, and visitors using guest relation techniques while professionally representing the visions and values of ARMC-AHMC Inc. Works closely with the patient service representatives, reviewing their work for accuracy and assisting them in their duties as needed.

This position requires the full understanding and active participation in fulfilling the mission of AHMC-Anaheim Regional Medical Center and AHMC Inc. It is expected that the employee demonstrate behavior consistent with the core values of ARMC and AHMC Inc... The employee shall support AHMC-Anaheim Regional Medical Center strategic plan, goals, and direction of the performance improvement plan. The employee will also be expected to support all organizational expectations including, but not limited to; Customer Service, Patient's Rights, Confidentiality of Information, Environment of Care and ARMC and AHMC Inc. initiatives. Ensure timely verification and validation of authorizations for all Commercial and Managed care inpatients and other services as assigned.Contacts insurance companies via phone or website to secure authorization.Responsible to review all discharged managed care patients for evidence of authorization entry in the Authorization module.Obtains missing authorizations within 3 business days of patients discharge or in some cases within 7 days of admission.Responsible for checking bill hold weekly for pending authorizations.Assists with sending delinquent reviews and resending reviews not received by the Payors.Communicate effectively, build and maintain professional, cooperative relationships with Case Management and all departments that have direct or indirect impact on obtaining authorizations.Maintains analysis of authorization issues, by payer.Clearly documents all contacts and authorization information for all types of authorizations in the hospital system, complete standardized documentation requirements in expected format.Follows established hospital policies and procedures regarding authorization processes.Other duties as assigned.
High school graduate or GED equivalent preferred

+ Minimum of 3-5 years admitting/ registration and/or business office background

+ General knowledge of third party payors, PPO, HMO, POS, EPO, workers compensation, Medicare, Medi-Cal, and Cal-Optima preferred

+ Knowledge of insurance authorization/ tracking/ pre-certification preferred

+ Positive work ethic

+ Excellent interpersonal skills

+ Ability to communicate effectively

+ Strong organizational skills

+ Computer and typing skills preferred

+ Medical terminology preferred


Shift: Variable

External Company Name: AHMC Healthcare

Street: 1111 W. La Palma Ave

#LI-Remote

Shriners Children's is a family that respects, supports, and values each other. We are engaged in providing excellence in patient care, embracing multi-disciplinary education, and research with global impact. We foster a learning environment that values evidenced based practice, experience, innovation, and critical thinking. Our compassion, integrity, accountability, and resilience defines us as leaders in pediatric specialty care for our children and their families.

Job Overview

Shriners Children's is the premier pediatric burn, orthopaedic, spinal cord injury, cleft lip and palate, and pediatric subspecialties medical center. We have an opportunity for a remote Patient Access Insurance Verifier - Epic for our Headquarters location.

This is being filled as a Temp role through a staffing agency.

Under the leadership of the Corporate Patient Access Manager, the Patient Access Insurance Verifier - Epic is an active member of the Patient Financial Services and Patient Access team that delivers support consistent with the strategic vision, goals, philosophy and direction of Shriners Children's (SHC) organization. The Patient Access Insurance Verifier - Epic is responsible for determining the status of a patient's insurance eligibility/coverage by contacting the appropriate insurance or third party payor in accordance with Shriners Hospitals for Children policies and procedures. The Insurance Verifier - Epic will have a thorough knowledge and understanding of Commercial, Managed Care, Medicaid, Managed Medicaid and Medicare payor guidelines and eligibility criteria. The Insurance Verifier - Epic will report into Shriners Children's headquarters office, but perform insurance verification for assigned hospitals located throughout the country.

Shriners Children's is an EOE/Drug-Free, Smoke-Free Workplace.

Responsibilities

Position Responsibilities:

* Under direction from the Corporate Patient Access Manager, performs insurance verification functions for assigned SHC hospitals
* Updates encounters in Shriners Children's I.S. (SHCIS) with the appropriate eligibility and COB status
* Documents in the health plan comment field on the encounter all actions that have been taken on the account related to insurance verification
* Updates health plans as needed based on feedback from the insurance company.
* Plans and organizes the work and activities of area of responsibility to ensure department and corporate goals are met
* Maintains a detailed level of knowledge of all payors authorization/referral guidelines and updates all appropriate fields in SHCIS to drive encounters to worklists
* Attends workshops and seminars, read manuals and updates to maintain a high level of knowledge of all payor criteria
* Makes recommendations to Manager of Patient Access for quality and efficiency improvements
* Completes special projects as directed by the Manager of Patient Access
* Identifies Cerner system issues, assists in identifying root causes of issues and submit recommendations to Manager of Patient and IS department for resolution
* Performs other related job duties as assigned
* Coordinates and prioritizes assigned activities to achieve maximum productivity
* Demonstrates a positive and professional image at all times when interacting with management, staff and others
* Responds positively to necessary changes in the workplace
* Maintains professional competency, according to department policies, procedures and protocols
* Assumes responsibility for professional growth and development

Qualifications

Experience Required/Preferred:

* 3 years' experience required working as an Insurance Verifier within an acute care hospital, physician practice or other healthcare setting
* 1 year of experience working with Epic EMR required
* Experience working within a Children' hospital experience preferred

Education Required/Preferred:

* High School Degree or GED required

Knowledge, Skills & Abilities:

* Strong analytical and problem solving skills
* Well-developed communication skills required
* Exhibits competency in the use of Microsoft Word, Excel, Word Perfect, PowerPoint, Visio

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Work Shift

Day

Work Day(s)

Variable

Shift Start Time

8:00 AM

Shift End Time

5:00 PM

Worker Sub-Type

PRN

Being an employee at Children's is more than just protocols and medication rounds-it's knowing when a hug is the most important thing in the world to a child. It's knowing that sometimes laughter really is the best medicine. But, most important, it's giving patients and families exactly the care they need, when they need it.

Job Description

Authorizes and pre-certifies services by coordinating and performing activities required for verification and authorization of insurance benefits for services. Proactively identifies resources for patients and may communicate with families the financial resources available to patients whose health plan does not include coverage for services, coordinating counseling services with Financial Counseling as required. Collaborates with Appeals department to overturn claims denied as well as Managed Care department in contract negotiations. May initiate and perform revenue cycle activities required for pre-registration. Works collaboratively with team members to provide quality service to proactively support efforts that ensure delivery of safe patient care and services and promote a safe environment at Children's Healthcare of Atlanta.

Experience

* Completion of an externship approved by Children's or one year of experience in insurance verification or an assigned clinical discipline

Preferred Qualifications

* Bachelor's degree
* Experience in a pediatric hospital

Education

* High school diploma or equivalent

Certification Summary

* No professional certifications required

Knowledge, Skills and Abilities

* Working knowledge of basic medical terminology
* Demonstrated multitasking and problem-solving skills
* Ability to work independently in a changing environment and handle stressful situations
* Must pass typing test with at least 50 words per minute
* Demonstrated arithmetic and word mathematical problem-solving skills
* Must be able to speak and write in a clear and concise manner to convey messages and ensure that the customer understands whether clinical or non-clinical
* Proficient in Microsoft Word/Excel/Outlook, SMS, Epic, CSC Papers, scheduling systems (e.g., NueMD, RIS, SIS), IMS Web, Report Web, and insurance websites (e.g., BCBS, RADMD, WebMD, Wellcare, Amerigroup, UHC)
* Must be able to successfully pass the Basic Windows Skill Assessment at 80% or higher rating
* May require travel within Metro Atlanta as needed
* Strives for adult-to-adult relationships with colleagues, subordinates, and superiors

Job Responsibilities

1.Interviews patients and/or family members as needed to secure information concerning insurance coverage, eligibility, and qualification for various financial programs.

2.Coordinates and performs verification of insurance benefits by contacting insurance provider and determining eligibility of coverage and communicates status of verification/authorization process with appropriate team members in a timely and efficient manner.

3.Provides clinical information as needed, emphasizing medical justification for procedure/service to insurance companies for completion of pre-certification process.

4.Confirms referring physician has obtained prior authorization as needed from insurance company for all scheduled healthcare procedures within assigned department/area.

5.Contacts referring physicians and or/patients to discuss rescheduling of procedures due to incomplete/partial authorizations.

6.Acts as liaison between clinical staff, patients, referring physician's office, and insurance by informing patients and families of authorization delays/denials, answering questions, offering assistance, and relaying messages pertaining to authorization of procedure/service.

7.Maintains tracking of patients on schedule, ensuring that eligibility and authorization information has been entered into data entry systems.

8.Pre-screens doctor's orders (scripts) received for new patients to ensure completeness/appropriateness of scheduled appointment.

9.Collaborates with Appeals department to provide all related information to overturn claims denied.

10.Monitors insurance authorization issues to identify trends and participates in process improvement initiatives.

11.Responds to all inquiries from throughout the system and outside related to authorization/pre-certification issues.

12.Provides ongoing communication to physician offices, patients/families, and others as necessary to resolve insurance authorization issues.

Primary Location Address

1575 Northeast Expy NE

Job Family

Patient Financial Services