Quality Control Representative

Overview

Under general supervision, this position is responsible for reviewing demographic, employer, and correcting billing information and ensuring that accounts are verified and authorized prior to bill print. If the account lacks verification and/or authorization the Quality Control Representative is responsible for obtaining the missing information.

Audits ER, Main Admitting, Ancillary and Breast Center registration to ensure accuracy. Must be familiar with all demographics and able to identify the guarantor, guarantor address, insured and next of kin information.

Able to identify all insurance cards, HMO's, PPO's, HMO/Medicare and Medi-Cal.

Must be accurate when updating all registrations. Able to recognize potential problems and recommend corrective action or additional training when necessary. Multi-task oriented with emphasis on detail is essential. Must be able to prioritize time and customize the essential job function.

• 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 AHMC- ARMC and AHMC Inc.. The employee shall support AHMC- Anaheim Regional Medical Center's strategic plan and 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 AHMC Inc. initiatives.

Responsibilities

Consistently applies infection control policies/practices.

Meets population/age specific competencies.

Attends department specific education/training, inservices, and staff meetings.

Department specific performance improvement project.

Reconciles the prior day's registrations with the census report (IP, OP, OPS, & ER) to ensure all accounts are reviewed and updated for accuracy. Maintains effective workflow by reconciling prior day's registrations against the census and OP reports.

Prints a face sheet on any missing accounts. Reviews, corrects, verifies, and updates demographic, billing information to ensure that the account doesn't hit the failed bill report. Ensures that all errors are corrected in the CPSI registration system before bill drop.

Reviews bill-hold reports for admitting deficiencies and maintains communication with registration, business office and other departments. Documents all interactions/ information in the CPSI account notes.

Verifies missing insurance benefits, obtains eligibility, benefit coverage, authorization and tracking numbers, when applicable. Working knowledge of insurance contracts.

Verifies missing insurance coverage, eligibility, LTM and effective date in a timely manner. Documents insurance coverage in account notes. Obtain authorization, pre-certification and tracking numbers, as required.

Works closely with the Financial Counselor, if needed to discuss possible linkage to Medi-Cal or MSI. Skilled in identifying problems, such as OP vs. IP procedures, possible denials, low benefits, non-covered services/ procedures, and analyzing a variety of factors to determine the need for further follow-up. Refers accounts to supervisor as required.

Obtains missing registration information and forms. Obtains missing signatures on all registration forms. (COA, MSP, etc.) Contacts patients for missing information.

If needed, contacts physician's office, employer and insurance company. Distributes updated forms to business office, and nursing unit.

Performs quality review of accounts, corrects errors and distributes face sheets to appropriate departments. Review registrations for correct insurance code and ensures information in B.O. jacket is accurate for timely reimbursement.

Maintains registration accuracy within the admitting/ Registration departments. Includes maintaining the QA report to include training sessions, when applicable:

Trains the registration staff on errors, such as the insurance code, diagnosis, employer, next of kin, and demographic information.

Assists the staff in maintaining a 95% accuracy rate. Maintains QA reports on every employee.

Collects any unmet deductible/ co-payment/ co-insurance from the patient. Reviews the insurance benefits for copay amount. If patient was unable to pay at the time of registration, the QC analyst will send a copay letter to the patient.

Maintains effective working relations with coworkers, case management, nurses, physicians, and other hospital staff members in order to ensure workflow effectiveness. Relates in a professional and friendly manner with all customers by: identifying themselves; using courteous tone of voice; uses telephone etiquette despite pressure and conflicts or heavy volume of calls. Ability to manage upset or potentially distressed patients, resolving issues within their control, making patients feel cared for, calm and willing to adhere to procedures.

Ability to understand the hospital's contracts and HMO, PPO, POS, EPO and government payors.

Ability to correct all registration errors and distributes updated information to all appropriate staff and departments.

Ability to calculate and collect any unmet deductible/ co-payment/ co-insurance or offer cash discounts when applicable. Ability to interpret the patient's financial responsibility.

Must have organizational skills to maintain work flow and follow up on missing authorization numbers.

Ability to demonstrate a consistent level of performance during periods of low census/ activity by assisting with insurance verification as needed.

Ability to communicate effectively in written and verbal form.

Performs assigned projects, clerical responsibilities, and other related duties as assigned.

Qualifications

• High school graduate or GED equivalent required

• Minimum of 3 years admitting/ registration and/or business office background

• Strong customer service skills

• Positive work ethic

• Computer and typing skills required

• Excellent interpersonal skills

• Strong organizational skills

• Ability to work independently; self starter

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

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

• Bi-lingual (English & Spanish) preferred

• Medical terminology preferred