Insurance Verification Representative
This position is responsible for timely and accurate pre-registration, insurance verification, and
upfront collection. The Insurance Verification Representative works to prevent avoidable denials
through compliance with payer pre-certification and authorization requirements. The employee
must accurately interpret managed care contracts and correctly calculate patient portion.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
1. Consistently supports and communicates the Mission, Vision and Values of St. Joseph Medical Center.
2. Follows the St. Joseph Medical Center Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
3. Promotes a culture of safety for patients and employees through proper identification, proper reporting, documentation and prevention of medical errors in a non-punitive environment.
4. Retrieve reservation/notification of scheduled service or walk in patient roster from scheduling and/or registration system/reports
5. Research patient visit history to avoid account and/or medical record duplication and ensure compliance with Medicare Payment Window Rules
6. Perform pre-registration, insurance verification, pre-cert/auth, deposit calculation, and telephone collection within 24 hours of receipt of reservation/notification for scheduled services and 48 hours prior to the date/time of the patient’s appointment (when scheduled within 72 hours of appointment)
7. Perform pre-registration, insurance verification, and pre-cert/auth same day for unscheduled/walk in registration
8. Perform pre-cert/auth same day for account status changes (unit to unit and/or level of care)
9. Follows insurance verification scripting to ensure the appropriate level of benefit and pre-cert/auth detail is obtained
10. Records detailed benefit and pre-cert/auth information in the appropriate electronic form at (registration system) to ensure availability for revenue cycle reference
11. Coordinates activities with physician offices to ensure compliance with pre-cert/auth and/or referral form requirements so that facility authorization can be obtained without delay; obtains fully compliant and authenticated order for services
12. Assigns accurate and appropriately sequenced payer code/Insurance plans
13. Utilizes payer websites and/or eligibility vendor to obtain real time eligibility and benefit detail; printing and/or cut-n-pasting detail to ensure availability for revenue cycle reference
14. Complete Medicare Secondary Payer Questionnaire to determine primary payer
15. Calculate patient cost share and perform telephone collection prior to service in accordance with upfront collection policy and procedure
16. Contact patient via phone (with as much advance notice as possible, preferably 48 hours prior to date of service) to obtain missing demographic information, quote/collect patient cost share, and instruct patient when and where to present at time of appointment
17. Communicates with hospital case management as needed to ensure clinical detail is provided to the payer in a timely manner
18. Utilize registration system notes to document important information related to verification, pre-cert, and upfront collection
19. Meet/exceed performance standards/productivity and upfront collection goals
20. Implements and follows system downtime procedures when necessary
21. Other duties as assigned
22. Supportive of the compliance program set forth by SJMC and demonstrated by:
- Upholds the Code of Ethics and Corporate Compliance.
- Adheres to and helps to enforce all compliance policies relevant to his/her area.
- Assures timely compliance education as requested by the Compliance Officer and/or through corporate initiatives.
23. Sets an example to all staff in their daily activities.
MINIMUM KNOWLEDGE, SKILLS AND ABILITIES REQUIRED:
- At least 3 years of Insurance Verification experience required
EDUCATION & TRAINING:
- High School Diploma or equivalent required
- Technical, critical thinking, and interpersonal skills relevant to area in order to effectively communicate with physicians, health team members, patients and families.
- Ability to prioritize work with minimal supervision, in order to independently carry out the duties of the position.
- Able to communicate effectively, both verbally and in writing.
- Additional languages preferred.
- Basic computer knowledge.