Patient Service Representative - Outpatient Eligibility/Procedural Authorization

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together in the Patient Revenue Management Organization (PRMO), the fully integrated, centralized revenue cycle organization supporting the entire health system.

This position is remote. Work hours: Monday - Friday, 8:00 AM - 5:00 PM.

About the Role

Responsible for accurate and complete patient accounts based on departmental protocol, policies and procedures, and compliance with regulatory agencies. This includes pre-admission, admission, pre-registration, and registration functions. Ensure all insurance requirements are met prior to patients' arrival and inform patients of their financial liability. Arrange payment options and screen patients for government funding sources. This role requires high customer service interaction with payors and physicians by phone.

Responsibilities

• Analyze insurance coverage and benefits for service to ensure timely reimbursement.
• Obtain all PAC and/or authorizations as appropriate.
• Facilitate referral to Financial Services for payment sources for uninsured patients.
• Determine if patient's condition is the result of an accident, performing complete research to identify the appropriate source of liability/payment.
• Schedule and pre-register patients, correcting as necessary all patient demographic and financial data.
• Resolve insurance claim rejections/denials and remedy expediently.
• Call patients to remind them to bring balances due, co-pays, co-insurance, and deductibles.
• Evaluate diagnoses to ensure compliance with the Local Medicare Review Policy.
• Perform duties necessary to ensure all accounts are processed accurately and efficiently.
• Promote and maintain excellence in customer service.
• Explain billing to patients according to PRMO credit and collection policies when discussing insurance.
• Implement appropriate collection actions and assist financially responsible persons in arranging payment.
• Make referrals to Financial Services Representative for counseling.
• Determine necessity of third-party sponsorship and process patients per policy and procedure.
• Examine insurance policies and other third-party sponsorship materials for sources of payment.
• Inform attending physician of patient financial hardship.
• Update the billing system to reflect the insurance status of the patient.
• Provide timely and effective customer service to internal customers.
• Assist with departmental coverage as requested.
• Obtain authorizations based on insurance plan contracts/guidelines, document in billing system per policy and procedure.
• Enter and update referrals as required.
• Communicate with insurance carriers regarding clinical information requested and resolve issues relating to coverage and payment.

Requirements

• Work requires knowledge of basic grammar and mathematical principles normally acquired through a high school education, with some postsecondary education preferred.
• Additional training or working knowledge of related business.
• Two to five years of experience working in hospital access, physician office, or billing and collections, or an equivalent combination of relevant education and/or experience.

Skills

• Excellent communication skills, both oral and written.
• Ability to analyze data, perform multiple tasks, and work independently.
• Must be able to develop and maintain professional, service-oriented working relationships with patients, physicians, co-workers, and supervisors.
• Must be able to understand and comply with policies and procedures.