Insurance Clearance Rep Senior

Main Responsibilities

• Acquires and maintains current knowledge of all payor requirements as it relates to patient/hospital responsibility for authorizations and hospital billing, including all Federal and State regulations.
• Performs all insurance authorization of inpatient and outpatient services, by accurately collecting and analyzing clinical data in support of payor guidelines and submits accordingly.
• Uses resources to determine appropriate procedure codes for authorization to ensure appropriate reimbursement.
• Consults with patient and appropriate departments for uninsured status, uncovered services, out of network status and situations where the only insurance is Third Party Liability or Workers Compensation and provides next steps.
• Initiates communication to the patient when authorization is not obtained and explains the potential financial responsibility.
• Maintains knowledge of all stand-alone computer software programs to verify eligibility and authorization.
• Safeguards patient information by maintaining knowledge of all HIPAA and compliance policies and guidelines.
• Maintains knowledge of all stand-alone computer software programs to verify eligibility and authorization.
• Ensures completion of all established policies and procedures for identification and notification of the Primary Care Physician in the case of HMO coverage.
• Identifies at risk balances related to Medicaid eligibility rules and communicates to Financial Counseling, Utilization Management, and physicians.
• Completes cancelations and accurately reschedules patient according to department procedures.
• Manages incoming and outgoing calls to complete pre-registration with patients.
• Pre-registers and registers patients using established procedures for computer entry for all ancillary and nursing units, keeping current with the specialized needs, and preparing necessary documents/records when necessary.
• Ensures accurate entry of patient demographic and insurance information in the ADT system with special attention to carrier code assignment, complete benefit, eligibility record and authorization data.
• Generates and processes all required documents for completion of registration, providing detailed education to the patient on the documents and forms requiring patient signature.

Knowledge, Skills & Abilities

• Ability to problem solve in a high profile and high stress area.
• Ability to prioritize and organize workload.
• Mathematical aptitude, effective communication, and critical thinking skills.
• Understanding of basic human anatomy and medical terminology.
• Excellent verbal and written communication skills.
• General computer knowledge.

Physical Requirements And Working Conditions

• Must be able to sit most of the workday.
• May include intermittent light travel.
• Operates all equipment necessary to perform the job.