Pre-Service Authorization Specialist - Appointment Center - Full-Time

Employment Type: Full time Shift: Day Shift Description: JOB SUMMARY Obtains accurate authorization and billing information to effectively authorize/pre-certify all patients entering Saint Joseph Health System (SJHS). Provides third party benefit verification for identified patients and other issues regarding the responsibilities to the related care plans. JOB DUTIES Actively demonstrates the organization's mission and core values, and conducts oneself at all times in a manner consistent with these values. Knows and adheres to all laws and regulations pertaining to patient health, safety and medical information. Knowledgeable of third party payer policies and procedures, documentation requirements, benefit plans, benefit limitations and additions, and employer groups. Acts as liaison between provider offices, physicians, health plans and ancillary departments. Maintains high quality customer service at all times, exhibiting courteous and professional behavior. Determines need for appropriate service authorizations (pre-certifications, third party payer authorizations, referrals) and will contact the physician/office and Case Management/Utilization Review colleagues as necessary. Ensures all authorization information is retrieved from fax server queue, authorization hotline and authorization team email in a timely manner, and is documented appropriately in patient accounts system. Reschedules and cancels patient test(s)/procedure(s) as determined by physician preference, and SJHS Delay and Deny policy. Complex situations may require coordination with appropriate scheduling team. Determine daily accounts that have not been financial secured for the next business day and report to Manager/Designee at afternoon huddle. Document status of each of the accounts not secured in patient accounts system as well as on the Delay/Deny Daily Log. Communicate with physician offices and patients when insurance payer denies authorization. If patient/physician decision is to continue with service, prepare and scan payer waiver for patient signature at time of registration. Communicate waiver details with Registration Team Lead to ensure proper completion of waiver. Performs insurance eligibility/benefit verification, utilizing a variety of mechanisms (RTE Emdeon, payer websites, and calling payers directly) and documenting information within the patient accounting system. Outcomes of the insurance eligibility/benefit verification activity will determine next steps (designation as self-pay, referral to financial counseling, etc.). Validates medical necessity of Medicare and Non-Medicare cases to ensure clinical and financial clearance. Contacts scheduling and/or ancillary department colleagues for clarification, if cases require clarification of diagnosis and/or test(s)/procedure(s). May prepare special reports as directed by the Manager to document utilization of the Pre-Service unit's services and patient flow (e.g., patient service time, call volume, etc.). May serve as a relief support if the work schedule or work-load demands assistance to Scheduling department. May also be chosen to serve as a resource to train new employees. Cross-training in various functions is expected to assist in the smooth delivery of departmental services. Performs concurrent and retrospective reviews of patient encounters on the Orders on the Wrong Encounter Report. Coordinates with appropriate departments to make changes necessary to correct the information entered on the wrong encounter. Validates complete and accurate documentation by Physician/Utilization Management colleague is met prior to completing Bed Management functions and patient type changes. Responsible for pre-registering the patient for upcoming visit(s) by interviewing the patient, family member and/or guarantor. Validates, obtains and enters demographic, clinical, financial, and insurance information into the patient accounting system. Utilizes multiple modes of communication (phone, fax, patient portal/e-mail, mail, etc.) and in a professional, accurate, efficient and courteous manner to obtain information and ensure good patient relations and a smooth billing process. During pre-registration calls, the position will provide information regarding directions, parking, transportation service, overnight accommodations, etc. Pre-Registration may be initiated by Scheduling staff with follow-up by the Pre-Service Specialist to ensure data integrity and completeness. Informs patient/guarantor of their liabilities and collects appropriate patient liabilities, including co-payments, co-insurances, deductibles, deposits and outstanding balances at the point of pre-registration. Calculates patient liabilities and provides financial education, referring the patient to financial counseling, as required. Documents payments/actions in the patient accounting system and provides the patient with a payment receipt in the collection of funds. Validates medical necessity (LCD/NCD review) of Medicare and Non-Medicare cases to ensure clinical and financial clearance. Contacts scheduling and/or ancillary department staff for clarification, if cases require clarification of diagnosis and/or test(s)/procedure(s). Performs other duties consistent with purpose of job as directed. JOB SPECIFICATIONS AND CORE COMPETENCIES Education: High school education required. Some post-secondary education preferred specifically in business or healthcare. Licensure: CHAA preferred. Experience: Three to five years of experience in health care or insurance setting. Interpersonal skills necessary to negotiate in high stress situations when representing SJHS in legal and adversarial situations. Working knowledge of third party payer regulations, requirements and laws governing admissions/registration procedures. Proficient in medical terminology, word processing and spreadsheet applications. Other Job Requirements: Ability to read, analyze and interpret Medicare compliance regulations. Ability to calculate figures and amounts such as discounts, co-insurance, co-pays and deductibles. This position requires a professional appearance. Superb customer service skills required over the phone and in person. Must be able to travel to all patient access sites. Working knowledge of medical terminology desirable. Basic computer skills are required. Performs job responsibilities to the highest standards and delivers "something more" that ensures a more complete and personally satisfying experience for every customer. Must be willing to participate in continuing education seminars as related to patient access. Assigned hours within your shift, starting time, or days of work are subject to change based on departmental and/or organizational needs. Our Commitment to Diversity and Inclusion Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law. Our Commitment to Diversity and Inclusion Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions. Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity. EOE including disability/veteran