The Pre-Access Representative pre-registers new patients according to department policy and protocol and other departments that may be assigned on an as needed basis. Contacts insurance companies and other third-party payers to determine pre-certification, pre-authorization and/or medical necessity requirements for basic and moderately complex hospital outpatient visits. Obtains pre-certification or pre-authorization prior to the scheduled service being performed. Liaisons with physicians and physician office staff when needed to obtain additional demographic, insurance or clinical information. Notifies the payer of admission if required.
Key Responsibilities (Pre-Access Representative):
Determines pre-certification, pre-authorization and or medical necessity requirements for hospital procedures and obtains it from insurance companies or payers and how many services covered. Contacts the physician’s office staff for additional required information pertaining to the visit. I.e., demographics, correct insurance information, or authorization.
Verifies that the insurance or payer coverage is still active and what it covers for the patient. Obtain, enter, and update demographic and other financial and clinical information necessary for financial clearance of schedule patient accounts.
Ensures that all required data elements are collected and validated for account creation in Revenue Cycle systems.
Assist with medical necessity documentation to expedite approvals and ensure that appropriate follow-up is performed.
Manage correspondence with insurance companies, physicians, specialists, and patients as required.
Process referrals and submit medical records to insurance carriers to expedite prior authorization processes.
Consult with supervisor or nurse manager to obtain clearance that treatment regimen is considered a medical necessity.
Receive requests for pre-authorizations and ensure that they are properly and closely monitored.
Review the accuracy and completeness of the information requested and ensure that all supporting documents are present.
Collaborate with other departments to assist in obtaining pre-authorizations in a cross-functional manner.
Makes patients aware of need for signed waiver for cases where pre-certification is required but not yet obtained.
Communicates patients estimated financial responsibility utilizing Experian Patient Payment Estimate and requests payment prior to or at the time of service; Patients who may need extended terms are referred to financial counselors for payment exceptions. Patients needing financial assistance are referred to appropriate programs.
Receives payments and issues receipts.
Other duties as assigned - Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee partner for this job. Duties, responsibilities and activities may change at any time with or without notice.
Education: High School Diploma Required or GED.
A minimum of two-year experience working with Meditech and insurance billing in a healthcare setting with knowledge in insurance payer regulations of primary/secondary coverage required.
Two (2) years’ experiences in Healthcare Revenue Cycle or related healthcare experience.
Prior experience with CPT code, ICD-10, HCPCS
Prior experience with clinical documentationSpecial Skills:
Ability to type 45 words per minute required.
Familiar with Microsoft office software programs such as outlook and excel required.
Medical terminology preferred.
Knowledge of ICD-10, CPT code, HCPCS
Knowledge of insurance verification, understanding deductible, coinsurance, and out of pocket expenses.
Knowledge of Local Coverage Determination (LCD) or National Coverage Determination (NCD) medical necessity
Meditech, eCW, Optum 360, Experian OneSource Passport
Knowledge of Microsoft
Call center experience
Customer service experience
Ability to quickly develop a rapport with customer base including to physicians, coworkers, and ancillary personnel.
Time Management skills
Physical Requirements: Light Physical Agility Test Rating (PAT)
While performing the duties of this job, the employee is frequently (activity or condition exists from 1/3 to 2/3 of the time) required to stand, sit, and walk; frequently to use hands, fingers; and frequently to talk or hear. The employee must exert up to 15 pounds of force occasionally (activity or condition exists up to 1/3 of the time), and/or up to 5 pounds of force frequently, and/or a negligible amount of force constantly to move objects. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job and will be tested by post offer PAT.