Insurance Clearance Representative

Advocate Health and Hospitals Corporation•Rome, GA

13d•Onsite

About The Position

The Insurance Clearance Representative is responsible for acquiring and maintaining current knowledge of all payor requirements related to patient/hospital responsibility for authorizations and hospital billing, including Federal and State regulations. This role performs insurance authorizations for inpatient and outpatient services by collecting and analyzing clinical data to support payor guidelines. The representative also determines appropriate procedure codes for authorization to ensure reimbursement, consults with patients regarding uninsured or out-of-network status, and communicates potential financial responsibilities when authorization is not obtained. They maintain knowledge of computer software for eligibility and authorization verification, ensure completion of policies for Primary Care Physician notification for HMO coverage, and identify at-risk balances related to Medicaid eligibility. Additionally, the role involves managing incoming and outgoing calls for pre-registration, accurately entering patient demographic and insurance information, and generating/processing required registration documents with patient education. The representative participates in staff meetings, stays updated on continuing education, and attends mandatory in-services and safety training. They actively participate in group projects for problem-solving and answer or refer patient, visitor, and employee questions by understanding various Advocate Aurora Health departments. Maintaining patient record confidentiality is crucial, adhering to HIPAA and compliance policies.

Requirements

High School Graduate.
Typically requires 1 year of experience in health care, insurance industry, call center or customer service setting.
Ability to problem solve in a high profile and high stress area.
Ability to prioritize and organize workload.
Mathematical aptitude, effective communication, and critical thinking skills.
Understanding of basic human anatomy and medical terminology.
Excellent verbal and written communication skills.
General computer knowledge.

Nice To Haves

None mentioned.

Responsibilities

Acquire and maintain current knowledge of all payor requirements related to patient/hospital responsibility for authorizations and hospital billing, including Federal and State regulations.
Perform insurance authorizations for inpatient and outpatient services by accurately collecting and analyzing clinical data in support of payor guidelines and submitting accordingly.
Use resources to determine appropriate procedure codes for authorization to ensure appropriate reimbursement.
Consult with patients and appropriate departments regarding uninsured status, uncovered services, out-of-network status, and situations involving Third Party Liability or Workers Compensation, providing next steps.
Initiate communication to the patient when authorization is not obtained and explain potential financial responsibility.
Maintain knowledge of all stand-alone computer software programs to verify eligibility and authorization.
Ensure completion of all established policies and procedures for identification and notification of the Primary Care Physician in the case of HMO coverage.
Identify at-risk balances related to Medicaid eligibility rules and communicate to Financial Counseling, Utilization Management, and physicians.
Manage incoming and outgoing calls to complete pre-registration with patients.
Pre-register and register patients using established procedures for computer entry for all ancillary and nursing units, keeping current with specialized needs, and preparing necessary documents/records when necessary.
Ensure accurate entry of patient demographic and insurance information in the ADT system with special attention to carrier code assignment, complete benefit, eligibility record, and authorization data.
Generate and process all required documents for completion of registration, providing detailed education to the patient on the documents and forms requiring patient signature.
Participate in department staff meetings and keep abreast of continuing education to ensure effective communication and maintain skill competency.
Seek out education opportunities to increase knowledge in department procedures as it relates specifically to scheduling needs for that area.
Attend all mandatory in-services 100% and complete all mandatory safety in-services and skill competencies as required.
Actively participate in group projects to problem-solve department issues.
Answer or refer patient, visitor, and fellow employee questions in an appropriate manner by maintaining operational knowledge of various Advocate Aurora Health departments.
Maintain confidentiality of patient records by following HIPAA and all compliance policies and guidelines.