Insurance Verifier

Overview

The Insurance Verifier provides a timely and accurate insurance verification; obtaining current eligibility, benefit coverage and authorizations to provide the necessary data to ensure reimbursement in a timely manner. This position identifies reimbursement resources for patient care and maximizing the effort to capture it. Identifies patient responsibilities, insurance reimbursement and other 3rd party reimbursement sources. Working knowledge of contracts with the ability to interpret per diem rates, case rates, stop loss, resulting in timely and accurate reimbursement. Maintains effective working relations with coworkers, case management, outside companies, and visitors using guest relation techniques while professionally representing the visions and values of AHMC- ARMC. Works closely with the patient service representatives, reviewing their work for accuracy and assisting them in their duties as needed.

This position requires the full understanding and active participation in fulfilling the mission of AHMC- Anaheim Regional Medical Center and AHMC Inc. It is expected that the employee demonstrate behavior consistent with the core values of AHMC- ARMC and AHMC Inc... The employee shall support AHMC- Anaheim Regional Medical Center’s strategic plan and goals and direction of the performance improvement plan. The employee will also be expected to support all organizational expectations including, but not limited to; Customer Service, Patient’s Rights, Confidentiality of Information, Environment of Care and AHMC Inc. initiatives.

Responsibilities

- Consistently applies infection control policies/practices.

- Understands and practices standard precautions for self and others in patient care activities.

- Understands and practices appropriate disease-specific isolation.

- Appropriately handles and disposes of sharps (i.e., needles, etc.) as required.

- Ensures sterility of supplies and equipment.

- Meets population/age specific competencies per unit specific addendum.

- Attends department specific education/training, inservices, and staff meetings.

- Attends mandatory inservices/educational/training activities.

- Submits all required paperwork on time.

- Verifies, by signature/initials, attendance at staff meetings or reading of staff meeting minutes.

- Participates in department specific performance improvement project.

- Actively assists in unit performance improvement monitoring.

- Knows and understands PDSA Model for Performance Improvement Program.

- Demonstrates understanding of performance improvement principles in job performance.

- Ability to understand the hospital’s contracts and HMO, PPO, POS, EPO and government payors.

- Ability to interpret the patient’s financial responsibility.

- Provides timely and accurate insurance verification, obtains eligibility, benefit coverage, authorization and tracking numbers, when applicable.

- Verify insurance coverage, eligibility of inpatients, outpatients and direct admissions in a timely manner.

- Obtain authorization, pre-certification and tracking numbers on all patient types, as required.

- Report registrations to the appropriate pre-certification Review Company and medical group/ IPA, as required.

- Skilled in identifying problems, such as outpatient vs. inpatient procedures, possible denials, low benefits, non-covered services/ procedures, and analyzing a variety of factors to determine the need for further follow-up. Referral the above to Case Management, Manager, Patient Advocates and Supervisor as required.

- Working knowledge of contracts with the ability to interpret per diem rates, case rates, stop loss, resulting in timely and accurate reimbursement.

- Documents insurance coverage, authorization numbers and billing data accurately in the financial system/ registration system to ensure timely reimbursement.

- All accounts have clear concise documentation regarding reimbursement status. Notifies manager or supervisor of problem accounts.

- Identify where the facility billing is to be sent (IPA vs Plan) and verify the billing address.

- Performs quality completeness review of accounts and reviews for errors.

- Review admissions/ registrations for accuracy, service code, patient type, spelling of diagnosis, missing diagnosis. Review all aspects of the registration fields to include insurance payor code.

- Works closely with the patient advocates on a daily basis and discusses any potential insurance or benefit issue.

- Work closely with supervisor to identify deficiencies and suggestions in ways to improve processes.

- Maintains effective workflow by reconciling prior day’s activity against the census, surgery and ancillary schedules.

- Ability to reconcile all accounts against registration reports.

- Maintains effective working relations with coworkers, case management, nurses, physicians, and other hospital staff members in order to ensure workflow effectiveness.

- Relates in a professional and friendly manner with all coworkers and hospital staff by: identifying themselves; using courteous tone of voice; uses telephone etiquette despite pressure and conflicts or heavy volume of calls.

- Ability to manage upset or potentially distressed patients, resolving issues within their control, making patients feel cared for, calm and willing to adhere to procedures.

- Must have organizational skills to maintain work flow and follow up on missing authorization numbers.

- Ability to communicate effectively in written and verbal form.

- Performs assigned projects, clerical responsibilities, and other related duties as assigned. This position should be able to perform a patient registration and have the ability to explain and obtain the admitting documents.

Qualifications

- High school graduate or GED equivalent preferred

- Minimum of 3-5 years admitting/ registration and/or business office background

- General knowledge of third party payors, PPO, HMO, POS, EPO, workers compensation, Medicare, Medi-Cal, and Cal-Optima preferred

- Knowledge of insurance authorization/ tracking/ pre-certification preferred

- Bi-lingual (English & Spanish) preferred

- Positive work ethic

- Excellent interpersonal skills

- Ability to communicate effectively

- Strong organizational skills

- Computer and typing skills preferred

- Medical terminology preferred