Reports and works under the direction of the Department Director/Manager/Supervisor. Reviews patient records using medical coding procedures. Verifies insurance eligibility and ensures the patients healthcare benefits cover the required procedures. Assists in educating patients regarding insurance. Coordinates daily administrative activities and patient support functions within the department. Ensures the appropriate and accurate documentation is maintained. Facilitates communication and serves as a resource to staff and patients as appropriate.
MISSION, VALUES and SERVICE GOALS
- MISSION: We deliver outstanding care, inspire health, and connect with heart.
- VALUES: Trust. Respect. Integrity. Compassion.
- SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.
Obtain prior authorizations for treatments by:
- Answers the many questions phoned in regarding insurance problems.
- Delivers accurate documentation to Insurance companies.
- Works closely with Physicians and clinical staff to obtain prior authorizations for treatments, procedures and medications.
Ensures accurate medical necessity documentation by:
- Reviews all Insurance bulletins for coding changes.
- Verifies treatment meets medical necessity per diagnosis given by providers.
- Refers any questionable diagnosis issues to the Manager/Director or Clinic Coordinator for clarification.
Audits for correct billing/documentation by:
- May audit billing for correct documentation required for reimbursement.
- Communicates and educates physicians and staff associates on any documentation issues in a timely manner in order to correct errors or omissions in the medical record.
Serves as point person for any insurance denials or claim errors by:
Works closely with Patient Accounts to properly follow up on insurance company appeals and denials.
Education/Training:
- Attends meetings regularly to stay abreast of insurance matters.
- Builds a rapport with key people at insurance companies to speak with when problems arise.
- Maintains online insurance portal knowledge and usage.
Contributes to the overall effectiveness of the department by:
- Processes report per established schedule and as requested.
- Serves as an on-site Insurance Specialist resource to department associates and physicians.
- Serves as a liaison and works closely with Patient Accounts, Medical Records, and department associates.
- Assists the Director/Manager/Supervisor and Clinic Coordinator with updating and training staff on coding changes.
- Communicates via telephone and in writing with patients, employers, and third party payers.
- Verifies that the billing exported out of department matches charges that are uploaded into the hospital and physician billing systems.
- Completes other job related duties and projects as assigned.
ORGANIZATIONAL RESPONSIBILITIES
Associate complies with the following organizational requirements:
- Attends and participates in department meetings and is accountable for all information shared.
- Completes mandatory education, annual competencies and department specific education within established timeframes.
- Completes annual employee health requirements within established timeframes.
- Maintains license/certification, registration in good standing throughout fiscal year.
- Direct patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
- Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
- Adheres to regulatory agency requirements, survey process and compliance.
- Complies with established organization and department policies.
- Available to work overtime in addition to working additional or other shifts and schedules when required.
Commitment to Beacon's six-point Operating System, referred to as The Beacon Way:
- Leverage innovation everywhere.
- Cultivate human talent.
- Embrace performance improvement.
- Build greatness through accountability.
- Use information to improve and advance.
- Communicate clearly and continuously.
Education and Experience:
A health insurance specialists must have extensive knowledge of the latest alphanumeric codes used in medical billing, so post-secondary training is required. The knowledge, skills, and abilities as indicated above are normally acquired through the successful completion of an associate's degree majoring in medical billing, medical coding, health informatics, health information technology or a related healthcare field certification. A minimum of 1 to 2 years of department specific work experience and/or insurance prior authorization and verification of benefits is required. Must have computer experience and be able to keep accurate insurance records.
Knowledge & Skills:
- The knowledge of medical terminology in regards to procedure and diagnosis codes, policies, legislation, equipment and professional disciplines.
- Demonstrated communications and interpersonal skills necessary to effectively interact with patients and guarantors.
- Knowledgeable in Medicare and Medicaid guidelines.
- Must be tactful in handling patient problems often of a highly personal and confidential nature.
- Must be able to maintain professionalism during frustrating interpersonal situations.
- Analytical skills are a must for health insurance specialists to check for any billing errors and make the necessary modifications.
- Detail-oriented with good organizational skills will help health insurance specialists file all essential insurance paperwork correctly.
- Health insurance specialists need the technical skills to work with electronic health records, coding software, email, and databases.
Working Conditions:
- Ability to adapt to change and close working conditions.
- Assigned hours within your shift, starting time, or days of work are subject to change based on departmental and/or organizational needs.
- May need to travel to other Beacon locations.
- Ability to adjust communication skills to the level of the patient and ordering providers.
Physical Demands:
- Prolonged periods of sitting and/or standing in front of a computer monitor.
- Requires the physical ability and stamina to perform the essential functions of the position.
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