Summary:Provide an excellent customer care experience to our Patients for your areas of responsibility through pre-certification or prior authorization for diagnostic imaging, surgeries and procedures, and verifying the Patient's benefits. Hours would vary between 7:00am- 5:00pm, M-F depending on business needs.
Essential Duties and Responsibilitiesinclude the following. Other duties may be assigned.
Verify insurances benefits for all visits at BJC.
Verify insurance benefits for all Physical Therapy encounters.
Complete prior authorizations and keep track of visits for all insurances for Physical Therapy.
Work with the Patient Advocate to research the benefits and variety of bills that the Patient can expect for their services.
Re-verify benefits for all Medical Assistance (MA) entitlees, assuring that we know and record the correct MA plan that the Patient has, as the MA HMO plans can change month to month.
Upon MRI approval and signing off on the MRI scheduled appointment send Patient Advocates a notification of any MRI copays.
Update the EMR system with all correct payor and Patient insurance demographic information, if a change is discovered upon VOB.
Notify BJOSC Registration of HST changes or updates for insurance information that need to be made for upcoming Surgeries or Procedures.
Inform Insurance Specialists of new or different insurance plans for Patients, in case outstanding claims need to be resubmitted to the correct payor.
Pre-certify and/or prior authorize diagnostic imaging, surgeries and procedures per payor requirements, following all cases to their resolution.
Use online tools wherever possible to obtain faster pre-certifications/prior authorizations and Verification of benefits, calling the payors whenever necessary.
Work with Clinical Services and Providers to obtain sufficient documentation and information to meet the requirements of the payors for pre-certs/prior auths.
Analyze and code using CPT codes for the proposed services, surgeries, and/or procedures in preparation for the pre-cert requests, whether on the phone or online.
Use the standard ICD 10 and CPT code references to make your determination in each case.
Abide by the CMS ASC Payables List and inform the Primary Nurse whenever a proposed service is not on the approved list, if the Patient has Medicare or the payor follows Medicare guidelines.
Follow the CMS Local Coverage Determinations (LCDs) whenever applicable to the case proposed.
Make sure that the diagnosis codes are in the progress note and that they are diagnoses that will be covered per patient's insurance policy for th procedure codes of the proposed services.
Request additional documentation when the initial requests are denied by the Patients' payors.
Work with Providers and Clinical Staff to set up peer-to-peer reviews when needed. Alert the Call Center staff when peer-to-peer is scheduled.
Refer all self-pay, tribal program, VA and active military TriCare requests to the Patient Advocate.
Refer all Workers Comp cases to the Work Comp Coordinator after doing the VOB and/or pre-certification for the Patient's health insurance.
Create and/or complete reports as needed or requested.
Create cases in the EMR system for MRI's to be billed correctly for some insurance carriers.
Prior authorize CMO's (custom molded orthotics) when Podiatry sends an alert.
Must have great attention to detail.
Special projects as requested.
Education/Experience:
1 plus years' experience with online and telephonic verification of benefits.
1 plus years' experience with online and telephone pre-certification and prior authorizations for services.
Experience or knowledge of ICD 9 CM and/or ICD 10 cm diagnostic and CPT procedural coding.
Previous experience in an electronic practice management and electronic medical records environment required.
Excellent verbal communications skills combined with compassion for our Patients required.
Experience documenting notes online required.
Basic use of Microsoft Excel and Word required.
High School graduate or equivalent.
Qualifications:
Prefer LPN, MA or HUC credentials and experience.
Extensive knowledge of all types of insurances (government, commercial, programs, private).
AAPC coding certification, CPC and in either or both ASC (CASCC) coding and/or orthopaedic surgery coding (COSC).
Previous experience working with physicians, providers and nurses preferred.
Patience and ability to work with people at all levels, internal and external, required.
Ability to help Patients or to get medical help for Patients in an emergency required.
Physical Demands: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. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to talk and hear. The employee frequently is required to stand; walk; sit; use hands to type; and reach with hands and arms. The employee is occasionally required to stoop, kneel, crouch and bend. The employee must occasionally lift and/or move boxes up to 20 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.
Essential Physical Requirements
Mark all responses using the following codes:
N = Never
O = Occasional, represents 1 to 33% or 1 to 2 hours of an 8 hour workday.
F = Frequently, represents 34 to 66% or 2½ to 5½ hours of an 8 hour workday.
C = Continuously, represents 67 to 100% or 6 to 8 hours of an 8 hour workday.
PHYSICAL ACTIVITY
N
O
F
C
Walking
X
Standing
X
Sitting
X
Reaching Shoulder Height
X
Reaching Above Shoulder Height
X
Reaching Below Shoulder Height
X
Climbing
X
Pulling 25 Pounds or Less
X
Pulling 25 Pounds to 50 Pounds
X
Pulling Over 50 Pounds
X
Pushing 25 Pounds or Less
X
Pushing 25 to 50 Pounds
X
Pushing Over 50 Pounds
X
Lifting 25 Pounds or Less
X
Lifting 25 Pounds to 50 Pounds
X
Lifting Over 50 Pounds
X
Carrying 25 Pounds or Less
X
Carrying 25 Pounds to 50 Pounds
X
Carrying Over 50 Pounds
X
Crawling/Kneeling
X
Bending
X
Twisting/Turning
X
Balance
X
Repetitive Movement (fine motor like typing, writing, keyboarding, filing)
X
Essential Physical Requirements Continued
PHYSICAL EXPOSURE
N/A
Unprotected Heights
X
Lighting Bright
X
Lighting Dim
X
Mechanical Hazards
X
Hazardous Substance
X
Infectious Diseases
X
Harmful Physical Agents (Heat/Cold)
X
Noise
X
Ionizing/Non-Ionizing Radiation
X
PHYSICAL ABILITY
ACCEPTABLE MINIMUM
Vision
Good
X
Poor
Blind
Color Vision
Normal
X
Impaired
Hearing
Normal
X
Moderate Loss
Deaf
Manual Dexterity
Good
X
Fair
Poor
Talking/Speech
Good
X
Fair
Mute
