Patient Access Insurance Specialist

Patient Access Insurance Specialist – Beacon Health System

Reports to the Patient Access Director or the Insurance Specialist Supervisor. Follows established Beacon policies and procedures to verify insurance coverage to ensure necessary procedures and hospitalizations are covered by an individual's provider. The Insurance Verification Authorization Specialist will assure authorization is obtained for all procedures and diagnostic testing to services being rendered. The Authorization Specialist will also initiate the authorization for direct admissions, emergency admissions, and emergency procedures.

They will work closely with medical staff, clinical staff, referring clinics, Beacon Outpatient Scheduling, Surgery Scheduling, Social Services, and Utilization Review departments. They will be responsible for communication with insurance carriers and/or providers for purposes of obtaining approval for services requiring authorization, pre-certification, and prior approval for admissions to Beacon or Epworth Center by using web-based tools, other electronic means where possible, or by telephoning and faxing when necessary.

Coordinating those visits with the correct paperwork and insurance verification, along with accurate documentation in the patient's medical record is essential. They will answer high volume of incoming phone calls as well as make high volume of outbound phone calls, with constant communication to the Utilization Review, Social Services, Beacon Outpatient Scheduling and Surgery Scheduling departments. Performs other clerical duties as necessary.

• MISSION:
  We deliver outstanding care, inspire health, and connect with heart.
• VALUES:
  Trust. Respect. Integrity. Compassion.
• SERVICE GOALS:
  Personally connect. Keep everyone informed. Be on their team.

• Verify demographic and insurance information is complete and accurate by...
• Updating the system after validation of the new patient's financial information.
• Obtains accurate insurance information and communicates with patient and/or physician office staff.
• Using the Cerner databases to locate/retrieve scheduled patients for admission/registration input into Access Management Office.
• Generating PHS and Surgi Net reports to facilitate verification of scheduled procedures.
• Explaining about the possible need to pre-certify with the patient's insurance carrier in order to ensure maximum coverage to the limits of the insured's insurance policy.
• Verifying and documenting insurance coverage via online eligibility systems, internet resources or via telephone.
• Validating medical necessity via the Cerner Medical Necessity Checker where applicable.
• Auditing the MSP (Medicare Secondary Payor) questionnaire by verifying that all fields are completed.
• Referring the patient to the Financial Counselors or Eligibility Specialists to secure satisfactory payment arrangements or financial clearance. Also, assisting in obtaining additional patient information, copies of insurance card(s) and church information.

• Verifying insurance coverage by calling the insurance company or using online eligibility systems to determine the patient's benefits under the insurance plan.
• Obtaining VOB information such as: co-payment, co-insurance, deductible, the amount of the deductible that has been met year-to-date, family deductible, maximum out-of-pocket limit and rehabilitation benefits.
• Run insurance eligibility software, make needed phone calls to insurance companies, fax authorization requests.
• Documenting all VOB information in the computer system.
• Obtaining pre-certification information from the insurance company's pre-certification unit (i.e., whether pre-certification is required, if the ordering physician has completed it, etc.).
• Securing authorization on all patients for ancillary, surgical, and out-patient testing/procedures/admissions.
• When the ordering physician has not completed the pre-certification, work with physician office and surgery scheduling or centralized scheduling to reschedule any procedures that are not fully authorized.
• Runs and ensures medical necessity is complete with proper CPT and ICD-10 codes as physician order specifies.
• For all government payors run CPT codes on the Medicare Inpatient Only Procedure (MIPO) list. If CPT codes are on the MIPO list, verify the patient is scheduled as a MIPO and confirm the Physician's office has obtained an inpatient surgery authorization if applicable.
• When the ordering physician has completed the pre-certification, documenting the authorization and releasing the account.
• Initiate authorizations for direct admissions, emergency admissions, and emergency procedures.
• Ensures all authorization obtained from referring facilities are accurate and complete.
• Identify out of network insurance plans and follow the out of network policy.
• Prepare Indiana Medicaid/HIP Universal PA form for Utilization Review.
• Keeps accurate worklists and documentation.
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