Pre-Access Specialist I

About the Role

Perform a variety of duties to determine eligibility and costs for diagnostic procedures and testing. Ensure documentation is current and accurate for payors and clinical staff.

Responsibilities

• Verify eligibility and obtain benefit information for diagnostic procedures and testing.
• Provide initial clinical documentation as requested.
• Update demographic and/or insurance information.
• Perform medical necessity check to determine in advance if the procedure or treatment is reasonable and necessary based on diagnosis.
• Document medical necessity checking outcome.
• Generate waiver/Advanced Beneficiary Notice (ABN) if medical necessity checking does not meet payer criteria.
• Scan waiver documentation into electronic medical record.
• Ensure notation is made for any documents that require patient signature.
• Accurately screens all applicable Medicare tests.
• Reviews Medicare Secondary Payor (MSP) queries to determine payor for Medicare and Medicare HMO patients.
• Initiate pre-certification process for diagnostic procedures and testing.
• Ensure all pertinent information is added to electronic medical record (EMR).
• Clarify orders or documents from providers to ensure that CPT and ICD-10 code is correct for procedure ordered and is authorized.
• Retrieve and submit clinical information.
• Provide communication when additional information is required, eligibility failed, medical necessity isn't supported or precertification wasn't approved.
• Create cost estimate for diagnostic procedures and testing.
• Documents estimated patient responsibility in EMR.
• Ensure all pre-certification, authorization and referral requirements have been completed prior to scheduled procedure.
• Obtain additional clinical information as needed.
• Maintain reference materials to ensure accuracy of information.
• Sets priorities that benefit the department and organizes time to complete the tasks.
• Can quickly adapt when new processes are introduced and/or existing processes are modified.
• Maintain productivity and quality standards as defined through the organizational and departmental goals and objectives.

Schedule

Mon - Fri, full time

Requirements

• Education: High School or GED required. Post-secondary education in a clinical field (e.g., RN, CNA, Radiologist Technologist, Phlebotomist, etc.) or health information management preferred.
• Experience: Minimum 1 year of clinical experience using electronic medical records required. Registration, insurance, or prior-authorization experience preferred.

Skills & Knowledge

• Skill using computers and office equipment.
• Skill organizing and prioritizing work.
• Skill with verbal and written communication.
• Knowledge of medical terminology.
• Knowledge of Microsoft Office suite.
• Knowledge of Medicare requirements.
• Basic knowledge of ICD 10/CPT coding.
• Ability to perform mathematical calculations.
• Ability to adhere to all workplace and safety requirements, regulations, standards, and practices.

Physical Requirements

Weight Demands: Light Work - Exerting up to 20 pounds of force.

Physical Activity:

• Not necessary for the position (0%): Climbing, Crawling, Kneeling
• Occasionally Performed (1%-33%): Balancing, Carrying, Crouching, Distinguish colors, Lifting, Pulling/Pushing, Standing, Stooping/bending, Twisting, Walking
• Frequently Performed (34%-66%): Fingering/Touching, Grasping, Keyboarding/typing, Reaching, Repetitive Motions, Sitting, Speaking/talking
• Constantly Performed (67%-100%): Hearing, Seeing/Visual

Job Hazards Not Related: Chemical agents, Biological agents, Physical hazards, Equipment/Machinery/Tools, Explosives, Electrical Shock/Static, Radiation Alpha/Beta/Gamma, Radiation Non-Ionizing, Mechanical moving parts/vibrations