Prior Authorization Utilization Review Jobs in Oregon

ST. CHARLES HEALTH SYSTEM

JOB DESCRIPTION

TITLE: Insurance Verification Specialist

REPORTS TO POSITION:Supervisor

DEPARTMENT: Pre-Arrival Services

DATE LAST REVIEWED: February 28, 2023

OUR VISION: Creating America's healthiest community, together

OUR MISSION: In the spirit of love and compassion, better health, better care, better value

OUR VALUES: Accountability, Caring and Teamwork

DEPARTMENT SUMMARY: The Pre-Arrival Services department specializes in ensuring that appropriate scheduling and insurance requirements are met, to ensure payment for services rendered. This team works with patients to assist them in understanding theirfinancial responsibilities regarding treatment forhospital and professional services. This includes providing insurance verification, estimates,preauthorization, and assistance programs to best practice standards. Refers patient to other St. Charles Health System programs/departments as needed. Track and monitor services required throughout their course of care.

POSITION OVERVIEW: The Insurance Verification Specialist coordinates and performs insurance verification confirming patient participation in health plan and obtains accurate benefit coverage. Validates or obtains pre-certification requirements with the rendering physician's office, third party carriers, and managed care providers as required by the patient's medical coverage. Contacts patients to advise them of co-pays and deposits as needed. Discusses pre-existing or benefit limitations with patients, provides professional, accurate, and timely service in all admitting functions and as requested by patients/families, physicians, visitors, or other hospital representative. This position does not directly manage any other caregivers. This position does not directly manage any other caregivers.

ESSENTIAL FUNCTIONS AND DUTIES:

Confirms patient participation in health plan and obtains accurate benefit coverage. Establishes co-pay, deductible, and co-insurance amounts, deposits and max out of pocket in accordance with St. Charles Health System credit and collection guidelines.

Communicates appropriate provider and facility information to health plan as part of the prior authorization or admission notification process. Has intermediate patient access knowledge of registration & insurance within the EMR.

Maintains working knowledge of Medicare, Medicaid, Commercial and HMO payors. Remains current on all insurance company changes/requirements applying authorization requirements. Assists physician offices in completing authorization requirements for an accurate authorization.

Submits documentation to obtain authorizations, verifies authorizations that are in place and accurate for procedures. Provides notice of observation or admission, for applicable services.

Contacts physician's office when authorization is missing or inaccurate. Tracks, updates and investigates current orders and tasks; managing orders through the system to provide up to date and accurate information. Obtains pertinent documentation from provider, facility and patient to ensure accurate prior authorization and patient assistance requests. Assist with patient education and follow up regarding the prior authorization and referral processes.

Starts the utilization management and continued stay review workflow by submitting notification to insurance companies for our bedded outpatients and inpatients within required timelines. Confirms with insurance companies whether ICD-10, HCPCS codes and type of stay ordered require an authorization and that physician's office has been obtained authorization or certifications when necessary.

Monitors and complies with regular changes by insurance companies. Ensures St. Charles Health System meets insurance requirements, and ultimately get paid for services rendered with the highest level of accuracy.

Provides estimates of cost for procedures and services.

Prepares required waivers on accounts for non-covered services, or as required by government plan. Notes the EMR with accurate benefit information. Notifies appropriate department where patient will arrive, to ensure waiver/ABN compliance on day of service. Develops and keeps updated waivers forms, insurance notes, policies and procedures. Documents activity within the EMR regarding all calls, correspondence, and related activities to each patient account, to assist other departments in understanding patients' coverage and patient responsibility.

Refers patients to SCHC financial assistance programs as needed. Provides patients with applications for St. Charles Health System Financial Assistance Program when appropriate. Assists with review, tracking and correction of denied claims.Uses electronic tools to discover insurance for self-pay patients.

Performs duties in accordance with department guidelines, seeks direction for issues outside guidelines.

Works in partnership with Utilization Management, Surgery Scheduling, Documentation Coordinators, Pre-Surgery Clinics, Billing, and Chargemaster.

Supports the vision, mission and values of the organization in all respects.

Supports the Lean principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.

Provides and maintains a safe environment for caregivers, patients and guests.

Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies and procedures, supporting the organization's corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.

Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient and accurate.

May perform additional duties of similar complexity within the organization, as required or assigned.

EDUCATION:

Required: High school diploma or GED.

Preferred: College courses in medical terminology.

LICENSURE/CERTIFICATION/REGISTRATION:

Required: N/A

EXPERIENCE:

Required: 1 year of experience in a healthcare setting and knowledge of insurance payers: Commercial, Third Party Payer, Managed Cared, Medicare, Medicare Replacements, Medicaid, Government and Self Pay.

Ability to use PC based office productivity tools (e.g. Microsoft, Microsoft Outlook, and Excel).

Knowledge of online resources for insurance benefits coverage and limitations, use authorization grids and other resources pertaining to plan exclusions. Basic knowledge of insurance coverage terminology and benefit plan descriptions.

Previous customer service experience in a fast-paced environment.

Preferred: N/A

PERSONAL PROTECTIVE EQUIPMENT:

Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely.

PHYSICAL REQUIREMENTS:

Continually (75% or more): Use of clear and audible speaking voice and the ability to hear normal speech level.

Frequently (50%): Sitting, standing, walking, lifting 1-10 pounds, keyboard operation, operation of motor vehicle.

Occasionally (25%): Bending, climbing stairs, reaching overhead, carrying/pushing or pulling 1-10 pounds, grasping/squeezing.

Rarely (10%): Stooping/kneeling/crouching, lifting, carrying, pushing or pulling 11-25 pounds, operation of a motor vehicle.

Never (0%): Climbing ladder/step-stool, lifting/carrying/pushing or pulling 25-50 pounds, ability to hear whispered speech level.

Exposure to Elemental Factors

Never (0%): Heat, cold, wet/slippery area, noise, dust, vibration, chemical solution, uneven surface.

Blood-Borne Pathogen (BBP) Exposure Category

No Risk for Exposure to BBP

Schedule Weekly Hours:

Caregiver Type:

Shift:

Is Exempt Position?

Job Family:

Scheduled Days of the Week:

Shift Start & End Time: