Patient Access Specialist (Differential Waiver)

Sanford Health•Watford City, ND

1d•Onsite

About The Position

The Patient Access Specialist reviews and validates insurance eligibility, prior authorization and/or referral of medication, procedures, etc., and determines if insurance meets prior authorization criteria. This role involves collecting necessary documentation, communicating with third-party payers, healthcare professionals, and customers to prioritize requests. The specialist verifies patient registration, confirms benefit coverage (including deductibles and out-of-pocket expenses), and researches covered benefits for ordered tests, procedures, and other services. A key responsibility is ensuring that prior authorization for medical services, including testing, procedures, surgery, Durable Medical Equipment (DME), and medications, is completed and confirmed. This includes obtaining diagnosis(es)/CPT code(s) from the medical chart or provider office, contacting third-party payers to determine the appropriate prior authorization process, and working closely with provider offices to obtain and clarify documentation for medical necessity. If medical necessity criteria are not met, the specialist guides provider offices regarding Advanced Beneficiary Notices (ABN) or waivers that shift financial responsibility to the patient. The role also involves reviewing professional services denials, working with clinics and payers on the appeal process, and assuring required referrals are in place. Outgoing referrals for care outside Sanford Health may also be handled. There may be minimal telephonic patient interaction regarding referrals. The specialist may notify insurance companies for inpatient services and procedures requiring observation periods. Work is documented in a case management module, and direction is provided to utilization management, case management, and nursing. Collaboration with case management, social work, utilization management, and other cross-functional teams across the enterprise is expected. Assistance with data design and management, including report and presentation preparation, is also part of the role.

Requirements

Minimum of two years of experience in a hospital or clinic setting required.
Understanding of medical terminology, insurance background, office equipment and computers is required.

Nice To Haves

Post-secondary education helpful.

Responsibilities

Reviews and validates insurance eligibility, prior authorization and/or referral of medication, procedures, etc.
Determines if insurance meets prior authorization criteria.
Collects necessary documentation and communicates with third party payers, healthcare professionals and customers to prioritize requests.
Verifies patient registration and confirms benefit coverage, including deductibles and out-of-pocket expenses.
Researches and verifies covered benefits for ordered tests, procedures, and other services.
Obtains diagnosis(es)/CPT code(s) from medical chart and/or provider office.
Contacts third party payer to determine appropriate prior authorization process.
Works closely with provider offices to obtain and clarify documentation to demonstrate medical necessity.
Follows up with provider offices with guidance for Advanced Beneficiary Notices (ABN) or waivers that releases the financial burden of scheduled services from the facility to the patient if medical necessity criteria are not met.
Reviews professional services denials and works with clinics and third party payers on appeal process.
Assures all required referrals are in place.
May work on outgoing referrals for care outside Sanford Health.
May have minimal telephonic patient interaction concerning provider referrals.
May notify appropriate insurance companies when patients have checked in for inpatient services and procedures requiring observation periods.
Documents work in case management module.
Provides direction to utilization management, case management, and nursing regarding what action needs to be taken.
Collaborates with case management, social work, utilization management, and other cross-functional teams across the enterprise.
Assists with the design and management of data including the preparation of reports and presentations.