Responsible for verifying insurance coverage and obtaining appropriate insurance authorizations for all scheduled medical procedures for Out of State new and established patients.
1. Serves as point of contact for authorizations and related insurance questions for all Out of State Patients.
2. Reviews, prioritizes and completes authorizations & referral requests of add on procedures daily for all Out of State patients. Manages tight deadlines and maintains constant communication with Executive Patient Ambassador’s to ensure timely approval of services and avoid missed authorizations.
3. Responsible for the identification and proper data entry of insurance demographics. Verifies specialty outpatient and inpatient insurance, both primary and secondary coverage (when applicable by service type), within set timeframes determined by Administrative Services Management. Verification includes obtaining and documenting covered and non-covered benefits, plan type, co-payment, co-insurance, out of pocket, and deductible amounts and determining contract and benefit eligibility.
4. Responsible for notifying the Patient Financial Counseling Office of any significant gaps in coverage and/or high co-pays or deductibles prior to services being rendered.
5. Obtains authorizations for inpatient admission, outpatient precertification. Follow up in a timely manner with insurance and NJH faculty to ensure prompt reimbursement. Documents authorizations or denied authorizations in appropriate systems as per department protocol. Responsible for conducting clinical screening and providing all required medical information to insurance companies, as necessary to facilitate the authorization process.
6. Meets productivity goals as established by Administrative Services and reports daily productivity data to supervisor.
7. Maintains a thorough understanding of all major insurance plans and all ancillary procedures conducted by National Jewish and medical terminology and coding practices.
8. Coordinates patient ancillary testing between insurance company, patient and clinical staff. Educates clinical team regarding patient insurance requirements and limitations.
9. Maintains communications with patients to keep them apprised of their insurance authorization and eligibility status. Acts as a problem solver with patients regarding their insurance plan.
10. Coordinates the authorization appeal process for services and or tests that are deemed not medically necessary. Refers cases requiring additional clinical review to National Jewish faculty and plan directors to ensure all services have all necessary approvals before service is rendered.
11. Coordinates retroactive authorizations with medical staff, ancillary departments and insurance plans as necessary.
12. Performs all other duties as assigned.
1. Performs, as directed, safety compliance and uses Personal Protective Equipment (PPE), as needed.
2. Participates in Quality Assessment (QA) and Quality Improvement (QI) programs, as directed.
3. Ensures compliance with The Joint Commission and all other Federal, State and Regulatory Agencies.
4. Responds promptly and sincerely to customer’s needs, requests and concerns via all communication forms using easily understood language and refraining from using inappropriate language and non-verbal gestures.
5. Maintains positive working relationships as a team player through problem solving issues, speaking positively about others, listening attentively and observing the Patient Bill of Rights and Confidentiality.
6. Increases customer service knowledge, skill and ability by participating in department and institution-wide specific programs.
7. Incorporates National Jewish’s identity (Science Transforming Life®) into daily functions. Speaks positively about the institution, provides customers with prompt service, maintains a clean and safe working environment, dresses appropriately based upon National Jewish safety standards, and departmental policies and wears an ID badge visibly.
Knowledge and Skills
Incumbent must be proficient in Microsoft Office Suite applications, including Outlook, Excel, and Word. Effective written and oral communication, critical thinking and problem solving skills required. Knowledge of some medical terminology and procedures is desirable. Incumbent must have the ability to handle multiple projects at once. Experience with third party payer billing regulations, reimbursement requirements, precertification, utilization management, and/or coding practices is highly desirable. EMR experience preferred.
High School Diploma or equivalent preferred. Associate’s degree preferred.
Certification and Licensure
A minimum of three (3) years of recent insurance related experience within a healthcare environment required. Prior outpatient hospital experience preferred.
- or - Any equivalent combination of Education and/or Experience
Position is an office environment. Frequent requirements may include: sitting for extended periods, entering and manipulating data on a workstation computer and participating in team/executive meetings. Approximately 75% of daily responsibilities will be working both one-on-one and in teams with other personnel and extended one-on-one contact in a quiet environment where hearing and listening is paramount. Must possess the ability to communicate by observation, verbal, written and listening; standing; walking; climbing stairs; stooping to remove/replace files; good hand-eye coordination; lifting, pulling, pushing, and upper body twisting while handling supplies and equipment; sitting while completing paperwork; using keyboard for PC and word processing needs. Occasional requirements may include: stand, walk, use hands to manipulate, handle or feel objects, tools, or controls, reach with hands and arms, stoop, kneel, and lift/move up to 25 pounds. Incumbent may be scheduled to work an alternate schedule to accommodate essential business needs routine travel by foot or automobile to alternate work/meeting locations, possibly during inclement weather.
No environmental conditions indicated. Professional office environment with time of each day spent in interaction with management/staff, in addition to planning and working autonomously. Requires teamwork and the ability to handle multiple interruptions; frequently fast-paced; high-pressure; occasionally variable-paced; variable pressure. Personal Protective Equipment (PPE) will be provided to each employee when needed as determined by policy. Utilization of PPE is mandatory. Estimated 1700 employees in the worksite.