Verification/certification of patient care services to ensure financial reimbursement. Responsible for insurance benefit verification & provision of clinical information for pre-certification for surgeries & other procedures & services as required by insurance companies. Interpret medical record documentation for patient history, diagnosis, & treatment options to facilitate authorizations. Communicates effectively & professionally with many stakeholders. Complete necessary forms for insurance companies & initiates appropriate follow-up. Process patient referrals to other specialties, both within Mercy Health System & to outside providers, if necessary. Utilizes excellent customer service by demonstrating written & oral communication skills. Documents thoroughly & according to department & health system expectations. This position requires moderate understanding of healthcare Revenue Cycle & the importance of evaluating & securing all appropriate financial resources to maximize reimbursement to the health system. This position assumes clinical & financial risk of the organization when collecting & documenting information on behalf of the patient. Performs other duties as assigned.
Responsibilities
Essential Duties and Responsibilities
- Identify all scheduled patients requiring pre-certification or pre-determination through various systems.
- Review patient schedules & acquire all data elements & information from the various systems to acquire precertification.
- Contacts insurance companies or employer groups to obtain precertifications, predeterminations, & determine eligibility & benefits for necessary services.
- Make necessary contact to follow up if there are insurance issues in order to obtain financial resolution & payment on account.
- Obtain necessary clinical documentation to use in the pre-certification process.
- Timely documentation of referrals/authorizations/pre-certifications in appropriate systems.
- Coordinates follow-up to ensure all payor requirements are met & payment is expected.
- Communicates with designated Mercy Partners, Patient Financial Counselors regarding outcome of precertifications, benefits & patient financial responsibility.
- Obtains insurance information to complete payor requirements.
- Maintains current knowledge of payor payment provisions & regulations.
- Keeps abreast of denials related to pre-certification & assist with appeal of denials as needed.
- Keep current of ICD-9/ICD-10 & CPT coding requirements.
- Ability to utilize computer software to complete pre-certification processes.
- Participates in educational programs to meet mandatory requirements & identified needs with regard to position & personal growth.
- Maintains logs & documents activity timely within patient accounting system.
- Understands & follows patient confidentiality policies.
- Additional duties as assigned or appropriate.
Culture of Excellence Behavior Expectations
To perform the job successfully, an individual should demonstrate the following behavior expectations:
Quality - Follows policies and procedures; adapts to and manages changes in the environment; Demonstrates accuracy and thoroughness giving attention to details; Looks for ways to improve and promote quality; Applies feedback to improve performance; Manages time and prioritizes effectively to achieve organizational goals.
Service - Responds promptly to requests for service and assistance; Follows the Mercyhealth Critical Moments of service; Meets commitments; Abides by MH confidentiality and security agreement; Shows respect and sensitivity for cultural differences; and effectively communicates information to partners; Thinks system wide regarding processes and functions.
Partnering - Shows commitment to the Mission of Mercyhealth and Culture of Excellence through all words and actions; Exhibits objectivity and openness to other's views; Demonstrates a high level of participation and engagement in day-to-day work; Gives and welcomes feedback; Generates suggestions for improving work: Embraces teamwork, supports and encourages positive change while giving value to individuals.
Cost - Conserves organization resources; Understands fiscal responsibility; Works within approved budget; Develops and implements cost saving measures; contributes to profits and revenue.
Education and Experience
*High school diploma or equivalent required.
*One year of healthcare registration, scheduling, or physicians' office experience required. Completion of 24 (twenty four) hours of coursework in a business or healthcare related field of study may be considered in lieu of healthcare office experience.
Certification and Licensure
N/A
Skills and Abilities
Excellent oral communication skills/organizational skills
Ability to handle stress & problem solve
Computer experience required
Knowledge of Epic desirable
Able to work independently
Special Physical Demands
The Special Physical Demands are considered Essential Job Functions of the position with or without reasonable accommodations.
While performing the duties of this job, the employee is regularly required to walk; use hands to finger, handle, or feel; reach with hands & arms; climb or balance; stoop, kneel, crouch, or crawl; & talk or hear. The employee is frequently required to sit & work at a computer for long periods of time. The employee is occasionally required to stand. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception & ability to adjust focus. While performing the duties of this job, the employee must have good manual dexterity to operate keyboard & telephone; repetitive finger/wrist movement associated with use of keyboard; prolonged sitting. The employee must be able to lift or move office related objects
Level of Supervision
Some independent judgment is required, but alternatives are limited by standard practices or procedures.
Supervises
This position has no supervisory responsibility.