SUPERVISOR'S TITLE: Manager
TITLES SUPERVISED: N/A
TOTAL NUMBER OF FTEs DIRECTLY OR INDIRECTLY SUPERVISED: 0
PURPOSE OF POSITION: To verify insurance coverage(s) and obtain pre-authorizations for scheduled services and medications for patients as well as begin pre-certification process for hospital inpatients. Meet payer authorization requirements to ensure maximum reimbursement. Collaborate with patients; families; healthcare providers; insurance providers and other internal staff to address a wide variety of patient health insurance matters.
Utilize systems to efficiently confirm receipt of or to obtain pre-authorization for scheduled services and medications. Collaborate with internal and external resources regarding specific authorizations scenarios. Use sound judgment to determine appropriate documentation to support authorizations. Contact insurance carriers, families and physicians for referrals, authorizations or pre-certifications. Work with team to make contact with families prior to all patient scheduled visits and/or services to confirm insurance eligibility, referrals/authorizations with minimal stress to the family/patient. Work with various reports within CCHMC systems and utilize resources appropriately such as Internet, Insurance payor websites, and internal software associated with pre-authorization. Understand and follow department policies or payor specific policies to obtain pre-authorizations and follow standards of documentation of all actions taken to assure information is available for others to understand and act upon. Remain current on pre-authorizations protocols.
Work independently and collaboratively with team to efficiently handle work volume and queues to meet or exceed productivity standards. Utilize systems and procedures in place for the department. Accurately collect insurance information and demographics, obtaining insurance authorization and entering the information into the required systems. Work various reports as assigned.
- Problem Resolution
Initiate calls to appropriate parties both internal and external to resolve issues. Escalate to Sr, IVR, Lead or Manager as needed. Notify Manager or Lead or appropriate staff regarding system errors, recurring divisional problems/errors identified within work queues or reports.
Serve as a liaison between Hospital/Physicians Billing Service, Admitting, Outpatient Surgery, Outpatient Department, Patient Financial Services, Utilization Review and other Cincinnati Children's departments. Multiple division support; cross trained in order to work insurance pre-authorization for multiple divisions.
- Insurance Verification and Pre-Certification
Utilize systems to ensure active patient coverage and efficiently document timely notification to insurance carriers of inpatient stays. Collaborate with internal and external resources regarding specific pre-certification scenarios. Use sound judgment to determine appropriate documentation to support notification and pre-certification. Contact insurance carriers and families for necessary information to begin notification and pre-certification process. Work with Utilization Review and other internal departments to ensure information needed for timely notification and pre-certification are available. Work with various reports within CCHMC systems and utilize resources appropriately such as Internet, Insurance payor websites, and internal software associated the documentation of pre-authorization, notification and pre-certification. Understand and follow department policies or payor specific policies to complete notification process and being pre-certification and follow standards of documentation of all actions taken to assure information is available for others to understand and act upon. Remain current on notification and pre-certification protocols.
Every 3-4 weekends IVRs back up ASRs in service to patients, families, staff, external agencies in the completion of patient registration and admission.
- High School Graduate OR Equivalent
- One year healthcare and/or insurance related experience
- Associate of Arts OR Equivalent
- Two years of health care experience with primary duties in a revenue cycle position SC only: with responsibility for obtaining/following up on health insurance authorization
- Pre-certification experience
- Knowledge of ICD-9/10 and CPT Codes
Using time efficiently and productively; prioritizing multiple tasks properly to meet deadlines; recognizing time constraints and adjusting work schedule to address them.
- Customer Service - Basic
Ability to respond to basic customer requests with patience and enthusiasm; understands the needs of customers and escalates issues when appropriate
- Diversity Appreciation
Understanding and showing respect and appreciation for the uniqueness of all individuals; leveraging differences in others' perspectives and ideas; appreciating cultural differences and adjusting one's approach to successfully integrate with others who are different from oneself
- Relationship Management
Setting the stage for constructive relationships by being accessible, approachable, and interpersonally engaged; developing and sustaining meaningful and productive bonds with others based on mutual respect
- Medical Terminology - Basic
Basic knowledge of medical terminology
- Computer Proficiency
Proficiency in basic computer applications such as Microsoft Office (PowerPoint, Word, Excel), e-mail, and internet
- Office Equipment
Knowledge of, and the ability to operate, standard office equipment such as computers, telephones, copiers, etc.
- Detail Orientation
Meticulously keeping track of details without becoming overwhelmed by them; being exacting, precise, and accurate; spotting minor imperfections or errors and taking action to correct them
- Independence and Teamwork
Ability to work autonomously, with independent judgment, as well as in a collaborative team environment.
- Work Ethic
Working hard to conscientiously and thoroughly complete work; pushing oneself to successfully continue working on a task in the face of obstacles or setbacks; working continuously and intensely over long periods of time
- Critical Thinking
Using inductive and deductive reasoning to formulate general rules or principles and apply them to work; identifying flaws in logical reasoning; understanding complex conceptual relationships; accurately detecting underlying themes or patterns in data
Excellent verbal, written and/or interpersonal communication skills