Patient Services Specialist | Cardiology Clinic

Monument Health•Rapid City, SD

23h•Onsite

About The Position

The Patient Services Specialist plays a vital role in ensuring timely and accurate patient access to medical services by managing the prearrival prior authorization services. This position enhances patient access to care by ensuring all scheduled medical service requests and referrals are financially cleared prior to the date of service provision through the performance of insurance eligibility validation, plan benefit verification, and any related financial clearance, prior authorization, and pre-determination processes. The role involves collaborating with healthcare providers, clinical staff, and various departments throughout Monument Health, as well as with the patient, to secure necessary authorization for services while maintaining compliance with all regulatory requirements. The specialist is also responsible for accurately verifying patient insurance eligibility and benefits coverage, utilizing various tools, and assessing service requests to determine the need for pre-certification or referrals. Maintaining a strong working knowledge of insurance payers and program contract requirements is essential. The position requires continuous competency in role-specific functions, adherence to productivity and quality standards, and creating a positive service experience. Documentation of pre-authorization information in the EHR system is crucial to prevent denials. The specialist engages with departments and clinical staff to communicate authorization needs, may assist with appeals and peer-to-peer reviews, identifies high-risk requests for financial assistance, and advocates for patients and providers regarding authorization approvals and denials. Additionally, the role may provide backup support for Patient Admissions and Registration. For medication authorization, the specialist confirms prescription coverage, coordinates prior authorization including documentation submission, stays updated on patient assistance programs, coordinates with staff for signatures, serves as a patient advocate, acts as a primary contact for inquiries, and monitors assistance medications for timely delivery.

Requirements

High School Diploma/GED Equivalent in General Studies

Nice To Haves

1+ years in Health Care Services, Customer Service, Patient Scheduling, Patient Billing Experience
Associates degree in Healthcare Related Field

Responsibilities

Collaborate with healthcare providers, clinical staff, and various departments throughout Monument Health as well as with the patient to secure necessary authorization for services while maintaining compliance with all regulatory requirements.
Accurately verify patient insurance eligibility and benefits coverage, utilizing tools such as Electronic Health Records (EHR), add-on software, direct payer websites, and telephone or fax communications to ensure accurate reimbursement and compliance.
Assess service requests to determine the need for pre-certification, pre-authorization (procedure or medication), or referrals, and communicate effectively with relevant stakeholders to secure approvals prior to the date of scheduled services.
Maintain a strong working knowledge of various insurance payers, payer plans, and program contract requirements to facilitate appropriate insurance verification and authorization processes.
Continuously meet competency requirements to sustain the necessary skills, knowledge, and abilities for role-specific functions, while adhering to productivity and quality performance standards.
Create a positive service experience by being polite, compassionate, and professional with all internal and external customers.
Document pre-authorization information accurately in the EHR system, ensuring that services scheduled by internal and external providers meet all financial clearance criteria and have approved authorization in the time allowed by the payers and programs to prevent denial or penalty assessment.
Engage with departments and clinical staff to communicate the need for pre-authorizations or referrals promptly, working to prevent delays in patient care.
May include requests for assistance with managing appeals as well as the facilitation and coordinating peer-to-peer reviews when needed.
Identify high-risk requests that may require financial assistance and counseling and assist patients by providing guidance on available resources, financial assistance, or payment arrangements.
Advocate for patients and providers by addressing challenges related to pre-authorization approvals and denials, working closely with leadership to resolve issues and ensure compliance with financial clearance policies.
Provide backup support for Patient Admissions and Registration as needed.
Confirm prescription coverage and coordinate prior authorization, including collecting and submitting required clinical documentation (i.e. provider notes, labs and treatment history).
Stay up to date on patient assistance programs and guide patients through required application documentation.
Coordinate with providers and nursing staff to obtain required signatures and documentation from patients and providers.
Serve as a patient advocate by regularly communicating with pharmaceutical companies, providers and patients.
Act as primary contact for patient inquiries about medication authorizations and assistance programs.
Monitor assistance medications to ensure timely delivery and continuous patient access.