Job Description

The Insurance Authorization & Cost Estimate Specialist Lead is responsible for facilitating the concerted efforts of the Team to achieve and sustain desirable levels of customer service, accuracy of patient information for authorizations, estimates and patient assistance efficiently. This individual works in an integrated, harmonious manner with other team leads, departments and managers. The Lead serves as a mentor and role model for fellow team members through demonstrating an outstanding work ethic, superior technical knowledge, and concern for the values and mission. Maintains access to resources and insures that accounts are complete and secure. This role will lead the team to collect necessary insurance benefit and clinical information to properly authorization the ordered service with the patient’s insurance company. This includes steps to support insurance and benefit verification, pre-certification, and pre-authorization processes. The Lead Specialist must have clinical knowledge of services so appropriate information can be communicated/given to the insurance company which will ensure the service is rendered in the correct level of care. Reimbursement for the service rendered is dependent upon the insurance benefit verification process and meeting the authorization requirements of the insurance company. This role must also determine when the patient is under-insured so that additional funding sources can be evaluated and applied. Once authorized, the lead specialist determines the cost for the service by applying the patient benefits / coverage information and estimate functionality accessible through IT applications. This process is essential to ensuring the patient understands their financial responsibilities for the service rendered. This is a very dynamic environment as insurance plans, benefits, and coverage structures change frequently and the turnaround is essential so that treatment is not delayed. This individual will need expert knowledge of insurance plans, insurance regulations, and insurance benefit and coverages as they relate to the service rendered. Additionally, this team serves as a point of contact within the organizations for questions and issues as they relate to insurance plans and coverage information. The duties and responsibilities this individual performs is solely dependent on the organization receiving reimbursement for the service rendered and ensuring the patients cost are clearly identified.

Lead Duties

• Works complex problem accounts, serves as point of contact for addressing account issues, patient concerns, or billing and insurance questions
• Oversees the Insurance Verification/Pricing Transparency/FC team members responsibilities and duties.
• Develops team members through group and one-on-one training and in-services
• Implements, monitors, and appropriately reacts to quality assurance mechanisms
• Develops and revises insurance verification/estimation and financial counseling procedures, coordinating with other revenue cycle and clinical teams to ensure overall revenue cycle efficiency.
• Facilitates, implements, and monitors qualitative and quantitative work performance expectations
• Serves as point of contact for addressing account issues, patient concerns, or billing and insurance questions
• Resolves operating issues
• Co-develops, communicates, and tracks progress towards meaningful goals
• Prepares staffing schedules, posts vacations, etc

Insurance Verification

• Utilizes online systems, phone communication, and other resources to verify eligibility and benefits, determine extent of coverage, secure pre-authorizations, and determine patient liabilities within a timeframe before scheduled appointments determined by The Christ Hospital Health Network and during or after care for unscheduled patients
• Verifies medical necessity in accordance with the Centers for Medicare & Medicaid Services (CMS) standards, and communicates relevant coverage/eligibility information to the patient
• Communicates with patients, physicians, clinicians, front-end staff, or translators to obtain missing patient demographic or insurance information
• Coordinates benefits by effectively determining primary, secondary, and tertiary liability when needed
• Obtains pre-certifications and pre-authorizations from third-party payers in accordance with payer requirements
• Provides collections team with personalized patient estimates of financial responsibility based on insurance coverage or eligibility for government programs
• Remains updated on rates and changes to pricing/estimation system as necessary in order to ensure price estimates remain accurate
• Alerts physician offices to issues with verifying insurance and/or obtaining pre-authorizations
• Demonstrates understanding of insurance terminology (e.g., co-payments, deductibles, allowances, etc.), and analyzes information received to determine patients’ out-of-pocket liabilities
• Communicates liabilities directly to patients and provides education on key insurance terms and rules; may often handle patients with more complicated insurance plans (e.g., workers’ compensation)
• Connects patients with financial counselors when further explanation or education is needed or requested regarding payment plans or financial assistance; may conduct some basic financial counseling duties as necessary

Estimates

• Provides collections team with personalized patient estimates of financial responsibility based on insurance coverage or eligibility for government programs
• Communicates liabilities directly to patients and provides education on key insurance terms and rules; may often handle patients with more complicated insurance plans (e.g., workers’ compensation)

Financial Counseling

• Oversees the Financial Counselors’ responsibilities including acting as the patient advocate to secure some form of sponsorship for non-insured, medically necessary services.
• Must have knowledge of application processes for government programs.

KNOWLEDGE AND SKILLS:

EDUCATION:

High School Diploma or GED w/minimum 3 years customer service experience in a hospital or physician office setting. Medical insurance knowledge 1 year.

Bachelor’s Degree in Healthcare Admin or related field, Government Program experience 1 year preferred.

YEARS OF EXPERIENCE: One to two years of registration or insurance verification related experience required. Two years registration/billing/insurance experience required.

Three years of registration experience preferred.

REQUIRED SKILLS AND KNOWLEDGE:

Strong Analytical Skills

Customer service experience required

Strong knowledge of the following:

EHR programs (e.g., Epic)

Medical terminology

ICD-10, CPT, HCPCS codes, and coding processes

Substantial knowledge of or experience with other front-end processes, including scheduling, pre-registration, financial counseling, and registration; understanding of the revenue cycle as a whole

Superb teamwork skills

Excellent time management skills and ability to multitask

Excellent writing, oral, and interpersonal communication skills

Strong understanding and comfort level with computer systems and payor regulations

Epic experience

35 wpm data entry

Excellent verbal communication skills including the ability to speak and listen affectively

LICENSES REGISTRATIONS &/or CERTIFICATIONS:

Annual Registration Competency Test at 95%, Stat Test