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Position: Pre-Service Center Verification Specialist

Department: Ambulatory

Schedule: Full Time

POSITION SUMMARY:

The Pre Service Center (PSC) Verification Specialist role belongs to the Revenue Cycle Patient Access team and is responsible for coordinating all financial clearance activities by navigating all pre-registration (to include acquiring or validating patient demographic, insurance, and other required elements along with insurance verification activities), obtaining referral authorization, or precertification number(s), pre-service cash collections. The role ensures timely access to care while maximizing BMCHS hospital reimbursement. This role requires adherence to quality assurance guidelines as well as established productivity standards to support the work unit's performance expectations. This position reports to the Pre Service Center Supervisor and requires interaction and collaboration with important stakeholders in the financial clearance process including but not limited to insurance company representatives, patients, physicians, Boston Medical Center (BMCHS) practice staff, case management and Patient Financial Counseling. This is a Remote Position.

JOB REQUIREMENTS

EDUCATION:

High School Diploma or GED required, Associates degree or higher preferred.

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:

EXPERIENCE:

1-3 years Hospital registration and/or Insurance experience desirable. At least one year of experience must be in a customer service role.

KNOWLEDGE AND SKILLS:

• General knowledge of healthcare terminology and CPT-ICD10 codes.
• Complete understanding of insurance is preferred.
• Demonstrated customer service skills, including the ability to use appropriate judgment, independent thinking and creativity when resolving customer issues.
• Exceptional interpersonal skills, including the ability to establish and maintain effective relationships with patients, physicians, management, staff, and other customers.
• Able to communicate effectively in writing.
• Requires excellent verbal communication skills, and the ability to work in a complex environment with varying points of view.
• Must be comfortable with ambiguity, exhibit good decision making and judgment capabilities, attention to detail.
• Knowledge of and experience within Epic is preferred.
• Demonstrates technical proficiency within assigned Epic workqueues and applicable ancillary systems, including but not limited to: ADT/Prelude/Grand Centrale.
• Must be able to maintain strict confidentiality of all personal/health sensitive information.
• Ability to effectively handle challenging situations and to balance multiple priorities.
• Basic computer proficiency inclusive of ability to access, enter and interpret computerized data/information including proficiency in Microsoft Suite applications, specifically Excel, Word, Outlook and Zoom.
• Displays a thorough knowledge of various sections within the work unit in order to provide assistance and back-up coverage as directed.
• Displays a deep understanding of Revenue Cycle processes and applies knowledge to meet and maintain productivity standards as outlined by Management.

ESSENTIAL RESPONSIBILITIES / DUTIES:

• Monitors accounts routed to registration, referral and prior authorization work queues and clears work queues by obtaining all necessary patient and/or payer-specific financial clearance elements in accordance with established management guidelines.
• Maintains knowledge of and complies with insurance companies' requirements for obtaining prior authorizations/referrals, and completes other activities to facilitate all aspects of financial clearance.
• Acts as subject matter experts in navigating both the BMC and payer policies to get the appropriate approvals (authorizations, pre-certs, referrals, for example) for the scheduled care to proceed. The PSC Verification Specialist is an important part of the larger patient care team and helps clinicians understand what payer requirements are necessary for the widest possible patient access to services.
• Supports BMC staff at all levels for hands-on help understanding and navigating financial clearance issues.
• Uses appropriate strategies to underscore the most efficient process to obtaining insurance verification, authorizations and referrals, including on line databases, electronic correspondence, faxes, and phone calls.
• Obtains and clearly documents all referral/prior authorizations for scheduled services prior to admission within the Epic environment.
• Works collaboratively with primary care practices, specialty practices, referring physicians, primary care physicians, insurance carriers, patients and any other parties to ensure that required managed care referrals and prior authorizations for specified specialty visits and other services are obtained and appropriately recorded in the relevant practice management systems for patient appointments/visits prior to scheduled patient visits or retro-actively if not in place at the time of the appointment/visit. Ensure that approval numbers are appropriately linked to the relevant patient appointment/visit.
• When it is determined that a valid referral does not exist, utilize computer-based tools or contact the appropriate party to obtain/generate referral/authorization and related information. Record the referral/authorization in the practice management system.
• Contact internal and external primary care physicians to obtain referral/authorization numbers.
• Perform follow-up activities indicated by relevant management reports and WQ's.
• Collaborates with patients, providers, and departments to obtain all necessary information and payer permissions prior to patients' scheduled services.
• Communicates with patients, providers, and other departments such as Utilization Review to resolve any issues or problems with obtaining required referral/prior authorizations.
• Work collaboratively with the practices to resolve registration, insurance verification, referral or authorization issue to the extent that these unresolved issues impact the ability to obtain a referral/authorization.
• Escalates accounts that have been denied or will not be financially cleared as outlined by department policy
• Interview patients, families or referring physicians via telephone in advance of the patient's appointment/visit whenever possible, to obtain all necessary information, including but not limited to, financial and demographic information required for reimbursement and compliance for services rendered.
• Accept registration updates from various intake points, including but not limited to those received via paper forms, internet registration forms, telephones located in practices and direct calls from patients.
• Ensure that all updated demographic and insurance information is accurately recorded in the appropriate registration systems for primary, secondary and tertiary insurances.
• Review all registration and insurance information in systems and reconcile with information available from insurance carriers. For any insurance updates, utilize any available resources to validate the updated insurance information, insurance plan eligibility, primary care physician, subscriber information, employer information and appointment/visit information. Contact patients as necessary if clarifications or other follow-up is required, and at all times maintain sensitivity and a clear customer friendly approach.
• For any patient who is new to Boston Medical Center, create a new registration record, accurately obtaining all required data elements, including generating a medical record number and complete a full registration for the patient.
• For self-pay patients or patients with unresolved insurance, and for financial counseling, refer patients Patient Financial Counseling.
• Process current copayments, coinsurance, and/or deductibles for scheduled visits and outstanding patient balances for prior patient accounts during the pre-registration process.
• Maintains confidentiality of patient's financial and medical records; adheres to the State and Federal laws regulating collection in healthcare; adheres to enterprise and other regulatory confidentiality policies; and advises management of any potential compliance issues immediately.
• Participates in educational offerings sponsored by BMC or other development opportunities as assigned/available and complies with all applicable organizational workflows, as well as established policies and procedures.
• Demonstrates knowledge & skills necessary to provide level of customer experience as aligned with BMC management expectations.
• Demonstrates the ability to recognize situations that require escalation to the Supervisor.
• Establishes relationships and effectively collaborates with revenue cycle staff to support continuous improvement aligned with BMC management expectations as outlined.
• Takes opportunity to know and learn other roles and processes and works together to assist with process improvement initiatives as directed.
• Consistently meets productivity and quality expectations to align performance with assigned roles and responsibilities.
• Handle telephone calls in a timely fashion, following applicable scripting and customer service standards. Appropriately manage all calls by either working with the customer or referring the call to the appropriate party.
• Regularly undergo Managed Care Quality Audits to achieve the required standard.

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).

Compensation Range:

This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, and licensure/certifications directly related to position requirements. In addition, BMCHS offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), contract increases, Flexible Spending Accounts, 403(b) savings matches, earned time cash out, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.

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