Patient Access Eligibility Specialist

Overview

JOB SUMMARY:

The Patient Access Eligibility Specialist is responsible for investigating, validating, and updating patient registration records to accurately reflect guarantor and third-party payor information. Team member will function in daily operations as a member of the eligibility team. Daily functions include: reviewing account demographics and third-party payor information for accuracy, verifying insurance eligibility via online portals and phone calls, updating account information with a high degree of accuracy, working collaboratively with other Patient Advocacy team members when discrepancies are found to ensure they are addressed in a timely fashion and in the best interest of the patient.

Team member must be very detail oriented and a professional at parsing and understanding eligibility response details and associated downstream implications. Team member must assist patients in a courteous and professional manner exemplified by CARTI values at all times.

• Performs pre-registration/registration processes for assigned cases, verifies eligibility, submits notifications and verifies referrals for new patient services.
• Handles a high volume of assigned cases without degradation of work quality.
• Verifies patients demographics and accurately inputs this information into the Practice Management System, including documenting the accounts thoroughly.
• Verifies and understands insurance benefits, documents patients responsibility based on copays/estimates at the time of service in a timely fashion prior to the patient being scheduled.
• Thoroughly understand payor eligibility rules and nuances and how they impact downstream operations at CARTI.
• Initiates appropriate processes based on company policy and procedures upon identification of eligibility investigation findings.
• Proactively shares knowledge, payor rules, best practices, policies, and operational changes with eligibility team members.
• Communicates with patients in a proactive, professional, and courteous fashion in order to attain any necessary information for appropriate account updates and benefits investigation.
• Communicates with administrative and clinical staff to resolve issues and/or patient concerns.
• Research coverage criteria with insurance companies, other third party documentation, and compendiums to determine eligibility for services in a timely manner. Utilize multiple insurance healthcare websites and portals.
• Independently investigates, documents, and operationalizes payor-specific requirements for unique / specialized eligibility scenarios.
• Independently and within a team identifies operational weaknesses as they pertain to eligibility verification and securing of payment for future services rendered by CARTI. Proactively reports findings to administration and participates in developing plans to mitigate negative impact of external requirements.
• Assists patients and guarantors with coordination of benefits as required
• Attains referrals from third party payors as required and appropriately documents in system, in accordance to the standards and policies developed by the departments
• Coordinates and Re-Schedules appointments as necessary
• Assists patients, team members, and visitors in a courteous and professional manner always in accordance with CARTI values.
• Acts as a backup and performs any duties performed by the other Patient Access Eligibility Specialists team members.
• Completes daily assignments/work lists.
• Updates insurance carriers for established patients.
• Facilitates and participates in gathering accurate patient billing information.
• Support the patient privacy/confidentiality policies and regulations under HIPAA for patients and their medical records.
• Enters patient, referrals, and correspondence/communication actions and other data in an information system.
• Daily work is accomplished with minimal direct supervision.
• Gathers pertinent information from insurance carriers, financial counselors, and other ancillary staff to make certain the patients financial obligations for services provided.
• Make outbound calls and oversees inbound and/or review correspondence received via fax or email efficiently, with a high touch and exceptional customer service to callers.
• Other responsibilities and projects assigned by management as needed.
• Demonstrate impeccable integrity in a professional and courteous manner at all times.

High School Diploma or its equivalent

• Minimum of 4 years experience working in a medical office or healthcare payor setting
• 3 years of medical insurance verification experience required.
• Exceptional customer service skills; ability to always remain professional and courteous
• Knowledge of basic medical terminology
• Basic computer skills
• Ability to maintain confidentiality in daily operations
• Ability to respond and resolve verbal and written inquiries
• Ability to identify problems and issues that may arise without direct supervision