Prior Authorization Clerk

Job Summary:

Performs pre-certification/insurance reviews on procedures, diagnostics, and any notifications to patients regarding those deductibles, insurance amounts payed or owed from the procedures & diagnostics. Advises patients on options for financial counseling or payment arrangements with patient financial services at Artesia General Hospital and physician practices.

ESSENTIAL FUNCTIONS:

• Answer phone calls

• Provides outstanding customer service to patients inquiring about their accounts.

• Confirms patient insurance eligibility and/or benefits.

• Discusses patient deductible, copay's, and collection amounts owed before procedures, diagnostics, or other tests.

• Audits charts for accuracy of initial insurance verification/eligibility and prior authorization.

• Communicates with clinic staff and patient services regarding patients who are self-pay or indigent. Assists with rough estimate costs associated with services rendered in clinics including procedures, diagnostics, or other tests.

• Correct address information as required for guarantor, patient, insurance companies, employers etc. Communicate those changes as appropriate.

• Discuss and educate guarantors and patients on various services offered by AGH and Clinics as well as methods of payment for those services including but not limited to Medicare, Medicaid, Insurance, Financial Assistance and other state and county assistance programs.

• Assist with the implementation of potential new systems and process changes.

• Assist with training new employees.

• Ensure accounts are followed up timely (within established payer guidelines).

• Follow up to ensure that copays, deductibles, or collections owed before procedures, diagnostics, or other tests are paid within the established timeframes

• Will work with clinics and those accounts identified through the system that require addition steps to ensure proper collection and payment.

• Is able to maintain established productivity standards.

• Will utilize electronic, web based or telephone communication tools

• Will provide feedback to management/supervisor regarding identified trends in clinic copays, prior-authorizations, and collections.

• Will be able to differentiate information on the Explanation of Benefits to determine next steps in resolution of collecting current or outstanding clinic balances.

ADDITIONAL RESPONSIBILITIES:

• Prompt response to e-mail and telephone calls.

• Exceptional interpersonal skills.

• Excellent communication.

• Excellent organizational skills.

• Assist Business Office Lead/Supervisor/Manager/Director as required or assigned.

• Performs other necessary duties as required to meet the goal of providing exceptional customer service to the community and health system.

• Demonstrate awareness of age specific, cultural and spiritual practices of patients, staff and visitors.

• Complete Annual training/recertification as required.

• Understands the functional status and physical needs of patients, staff and visitors.

• Will treat all customers, coworkers, medical staff and the communities we serve with integrity and service excellence at all times as measured by documented communications to the Department Director.

• Will abide by the policies of Artesia General Hospital related to compliance.

• Will attend departmental/team meetings as required.

• Will complete annual education and training requirements.

KNOWLEDGE/SKILL/ABILITIES:

• High school diploma or equivalent required.

• 1 - 3 years of experience in the healthcare setting (Hospital and/or medical office) working with insurance claims processing involving CPT, HCPCS, ICD-9CM, ICD-10CM and CMS regulations.

• Familiarity with CMS1500 and UB04 claim form completion.

• Strong analytical, oral, written communication skills.

• Familiarity with health insurance

• Proficient in Microsoft Word, Excel, Access, Outlook, and the like.

• Bilingual in Spanish and English a plus.

• Must be able to assess situations, identify issues/problems and prioritize duties.

• Reasoning Ability: Uses personal experience, knowledge and other outside resources to make logical decisions to solve problems.

• Utilizes Time Management and Organization skills.

• Strong attention to detail, is accurate and completes principle accountabilities timely.

• Professionalism.

• Understand medical terminology

AGE-RELATED COMPETENCIES: Demonstrates the basic knowledge and skills necessary to identify age-specific patient needs appropriate for this position.

Information Management: Treats all information and data within the scope of the position with appropriate attention to confidentiality, privacy, HIPAA and security policies/regulations.

Risk Management/Quality Management/Safety: Cooperates fully in all Risk Management, Quality Management, and Safety Activities and Investigations.

MINIMUM POSITION QUALIFICATIONS:

• Education - High school diploma or equivalent.

• Work Experience -

• Minimum 2 years of experience in the healthcare setting (Hospital and/or medical office) working with insurance claims processing involving CPT, HCPCS, ICD-9CM, ICD-10CM and CMS regulations.

• Familiarity with CMS1500 and UB04 claim form completion.

• Strong analytical, oral, written communication skills.

• Familiarity with health insurance and other third party billing practices and guidelines.

• Proficient in Microsoft Word, Excel, Outlook, and the like.

• License/Certification - none.

ENVIRONMENTAL CONDITIONS: Work environment consists of daily patient contact in a fast paced office setting.