Pre-Service Specialist

Job Summary

The Pre-Service Specialist monitors compliance with Federal and State regulations in the process of pre-certifying all procedures and services.  This specialist will communicate internally with leadership when encountering any pre-certification and/or billing issues.  Additionally, this specialist will communicate externally with the patient to provide clear expectations of financial responsibility.

Primary Job Responsibilities

1. Verifies all insurance on scheduled services and provides an estimate of the self pay portion to the patient.
2. Obtains pre-authorizations/pre-certification per payer requirements for scheduled and non-scheduled hospital and clinic services prior to services rendered and ensures authorization number is documented in the appropriate field in the system.
3. Ensures the clinical documentation is provided to the insurance when appropriate for all IP and OP services.
4. Monitors the approval of all observation, inpatient, and swing bed patients for adequate approval of covered days. Call the insurance company when appropriate to request additional days.
5. Inputs information for inpatient stays into the Medicaid IP Health Solution system for pre-certification approval.
6. Completes referral documentation and forms for patients being referred from Memorial Medical Clinics to a specialist.
7. Completed all United Healthcare referrals in the appropriate system.
8. Monitors the daily operations of Financial Counseling for scheduled services.
9. Reports all Financial Counseling, pre-authorization, pre-certification, and/or registration issues to the Director of Revenue Cycle.
10. Maintains effective communications with physicians, physicians’ offices, ancillary departments, other departments, and co-workers as is appropriate.
11. Helps to maintain a professional atmosphere for patients and clinical staff.
12. Demonstrates the ability to properly prioritize activities within the department as needed.
13. Assists the nursing staff by performing clerical duties for scheduled patients as needed.
14. Demonstrates good leadership qualities by maintaining a proper perspective on the ability to fulfill every department’s needs at the same time.
15. Works at establishing and maintaining a good rapport and professional working relationship with all departments within Memorial Hospital and all physicians’ clinics.
16. Demonstrates the ability to communicate with the public in a courteous and informative manner; maintains strong verbal and written communication skills.
17. Monitors activity related to Patient Financial Assistance, Precertification, and Pre collection.
18. Remains current with reimbursement requirements and insurance requirements for Pre-Authorization.
19. Obtains current basic knowledge of CPT and ICD-10 codes.
20. Proficient in the understanding of Co-pays, deductibles, co-insurances, and other insurance verbiage.
21. Routine contact with insurance companies, state agencies, collections agencies etc.
22. Communicates effectively with a wide range of age groups from the very young to the elderly and multiple socio-economic backgrounds.
23. Perform other duties as assigned or requested.

Required Qualifications

1. High school graduate or equivalent.
2. An extensive knowledge of CPT codes and ICD-10 codes.
3. Proficiency with all Microsoft programs including Word, Excel, and Outlook.
4. Basic accounting principles.
5. Extensive knowledge of computer related skills.
6. Mathematical skills and typing (30+ wpm) skills.
7. Clear, legible handwriting skills.
8. Proficiency in the use of an electronic 10-key calculator, fax machine, copy machine and accurately perform filing functions.

Preferred Qualifications

1. CPAT, RMA, CHAA certification or experience equivalent
2. 6 months or more of previous experience in a hospital Patient Financial Services Department
3. Experience with managed care contract terms
4. Medical terminology knowledge
5. 2-3 years of customer service experience

Pertinent Skills Required

1. Must be able to work well with people of all ages and nationalities.
2. Good human relations, written and oral communication skills.
3. Sound judgment and problem-solving skills are necessary.
4. Ability to distinguish difference between numbers and/or names that are similar, good filing skills.
5. Ability to prioritize and perform multiple tasks with many interruptions.
6. Requires manual dexterity for the operation of a keyboard and mouse.
7. Hearing must be within range of normal human conversation.
8. Specific vision abilities by this job include the ability to adjust focus.
9. Subject to many interruptions, variable, and unpredictable and/or stressful situations.
10. Clear, legible handwriting skills.

Physical And Environmental Demands

1. Ability to lift, carry, push, pull, or otherwise move objects up to 50 pounds in weight.
2. Capable of moving files and performing filing functions, i.e., reaching, stooping, bending, kneeling, crouching, crawling.
3. Frequent prolonged periods of sitting or standing.
4. Ability to verbally communicate with customers and co-workers.
5. Ability to walk, bend, and stand as needed.
6. Potential exposure to infectious and contagious diseases, blood and/or bodily fluids.
7. Subject to rotating weekend/holiday schedules.
8. Occasionally subject to irregular hours.