Insurance Coordinator - South Shore Health

Job Description Summary

The Insurance Coordinator is responsible for the admission process and insurance verification for patients and referrals. Responsible for and ensures compliance with third party payer requirements and acts as liaison between the department and the insurance company’s advocates for the patient to ensure appropriate receipt of benefits and coordination of rehabilitation services.

Job Description

ESSENTIAL FUNCTIONS

1 - REQUESTING SERVICES/PROVIDING PROGRAM INFORMATION
a. Responds to incoming calls requesting services and information regarding programs offered for all Rehab Services, completing insurance intake information from patients, physicians and other sources.
b. Identifies and coordinates appropriate services

2 - PRE-AUTHORIZATION
a. Creates an accurate database for all patients and verifies third party coverage.
b. Implements new insurance office procedures to streamline referral process
c. Obtains pre-authorizations/certification for services per payer guidelines before initial date of service
d. Enters into the data base and files in patients’ medical record referral information as it is received
e. Ensures complete collection of referral information, including insurance coverage utilizing on-line verification technology
f. (Passport) when possible, obtaining authorization information including number of visits approved, and dates services are covered
g. Accurately and legibly completes insurance tracking sheet for each patient and each discipline
h. Obtains pre-authorization/certification through various means (fax, telephone, website) for services per payer guidelines
i. Discussing financial liability and schedule accordingly, in a confidential manner when indicated
j. Develop effective relationships with payer representative to facilitate coverage and problem resolution
k. Provides documentation for third party payer benefits in a timely manner
l. Understands coordination of benefits and acts as a liaison between patients and clinicians.
m. Verifies and ensures accuracy of orders with regard to appropriateness for services, identification of a diagnosis, date and signature

3 - EXTENSION PROCESS/DENIALS
a. Ensures that patients receive optimum benefits
b. Overturns 100% of any denial notification received
c. Compiles and submits appeal letters on receipt of denial
d. Obtains continuing service approvals and provides/faxes clerical data/information to third party payers to ensure reimbursement/approval within 24 hours of request
e. Consistently ensures that documentation received for extension approvals are in the computer/medical record on date received and communicated to patient to ensure no interruption in care
f. Responds to, investigates, collects and submits appeal letters to third party payers for benefits and successful reversal on 95-99% if denials received
g. Compiles and submits appeal letters within 2-3 business days
h. Tracks insurance caps and patient treatment does not exceed monetary allowance as outlined by insurance company
i. Communicates relevant issues to clinician, patient and family in a timely fashion

4 - OBTAINING LETTERS OF MEDICAL NECESSITY
a. Work with patient accounts to obtain letters of medical necessity for all patients that are part of the Uncompensated Care Pool (UCP/Free Care)
b. Form letter for medical necessity will be faxed to MDs office each day patient is here for services up to third visit. If the letter is not returned by third visit, call will be placed to the MD
c. If self-pay at time of registration, insurance office must meet with patient to advise patient to contact our Financial Counseling Department to apply for Mass Health/UCP, or work out payment plan
 

5 - CUSTOMER SERVICE/CHECK –IN
a. Greets and acknowledges all patients and visitors, both in office and on telephone, with professionalism and directs to appropriate services.
b. Initiates and follows through with service recovery process while keeping all team members informed as needed
c. Monitors patient flow and attendance throughout the day frequently checking the waiting area and sign-in log, keeping patients informed of delays as needed
d. Fosters a pleasant and professional office environment in keeping with Culture of Service Excellence standards
e. Answers telephones by the third ring, using department accepted greeting and in professional tone in accordance with the hospital’s telephone etiquette standards
f. Checks phone messages each hour and responds to call within same business day

6- PRE-REGISTRATION AND REGISTRATION
a. Completes pre-registrations and registrations with respect for patient privacy, and understands the impact of data accuracy on hospital operations.
b. Determine acceptability of physician’s order with regard to clarity of diagnosis, appropriateness of discipline ordered, appropriate date, treatment plan in accordance with injury and initiates process to obtain corrected order if necessary
c. Ensures accurate registration of insurance information and communicates to patient in a confidential manner using the financial liability worksheet, and obtaining patient signature of understanding
d. Completes registration and data entry of admission by selecting correct MR number and account number, if not previously completed
e. Orients new patients to essential program guidelines and expectations (i.e. cancellation and no-show policy, co-pays) to facilitate optimal participation and comfort in the program.
f. Informs patients of their rights and responsibilities, HIPAA and completes all documentation,

7 - SCHEDULING APPOINTMENTS
a. Schedules rehabilitation appointments in an efficient, coordinated, integrated manner to maximize optimal utilization of resources and patient access to services
b. Completes a full set of appointments including single discipline, multiple discipline, both land and pool according to scheduling standards
c. Cancels and reschedules when possible all cancelled appointments at time of message received
d. Communicates with all appropriate staff in a timely manner any conflicts or difficulty scheduling visits
 

8 - CO-PAYMENT COLLECTION
a. Adheres to department standards for timely collection of co-payment, completing all documentation and delivery according to department standard
b. Identifies and corrects errors in co-payment ledger for accurate delivery to cashier
 

9 - LONG TERM PROJECTS AND DAILY ASSIGNMENTS
a. Works independently to complete daily assignments by the end of the shift and long term assignments by deadline established

10 - Staff will work to enhance the patient experience in every interaction.
a. Demonstrates professional courtesy in all interactions with patients, family and coworkers.
b. Answers all questions in a polite, professional manner or finds someone who can answer the question.
c. Able to handle difficult patients or situations in a calm, professional manner.
d. Able to report issues/concerns using the chain of command.

11 - Staff will work to together to facilitate a smooth department workflow:
a. Prints, reviews and inquires about all department specific reports as needed
b. Completes hand off communication with each shift change or time away from the front office
c. Able to complete weekly/monthly assignments according to rotating schedule0
d. Follows schedule for Retrievex process
e. Assists with ordering of supplies
f. Assists with taking minutes according to rotating schedule

12 - Staff is able to manage daily office functions:
a. Able to perform multiple work tasks efficiently and effectively
b. Able to maintain a high level of concentration at all times
c. Able to be able to identify within themselves when they may need time away from the front desk and to find the appropriate coverage
d. Participate in professional and appropriate conversations while at the front desk or while in the area of patients/family members
e. Able to work under pressure and to maintain composure during stressful situations
f. Able to provide a high level of service for all interactions at the front desk
g. Able to complete tasks according to assigned deadlines
h. Utilizes critical thinking and problem solving in day-to-day operations as well as in emergent situations.
i. Communicates appropriately and effectively following chain of command.
j. Demonstrates dependability and flexibility in meeting scheduling needs of the department.
 

JOB REQUIREMENTS

Minimum Education - Preferred

High School Diploma or GED

Minimum Work Experience

Two (2) years business office experience preferred.
Previous health care environment experience of two (2) years preferred

Required additional Knowledge, and Abilities

Demonstrates effective communication skills and proven organizational and interpersonal skills.
Knowledge of medical terminology and clinical knowledge

Demonstrated knowledge base and experience with third party reimbursement, and computer technology.