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Patient Precertification Associate

MedStar Health

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General Summary of position

Location: Georgetown University Hospital
Department: Radiation Oncology-Cyberknife
Status: Full-time, 40-hours per week
Schedule: Monday-Friday, 8:30am-5:00pm

The individual in this position provides assistance to patients in the department. The individual is responsible for coordinating all the functions and activities related to patient pre-certification/authorization including, but not limited to: accurate and complete patient registration in the approved organization electronic scheduling and billing systems and on-site insurance verification. These functions are performed in accordance with all applicable laws and regulations and Georgetown University Hospital’s (GUH) philosophy, policies, procedures and standards.</adoptpage></adoptpage></adoptpage></adoptpage>


Primary Duties and Responsibilities

  • Referrals/Authorizations
    Verifies eligibility and conformance to Georgetown Physicians Group (GPG), GUH and departmental managed care requirements and contracts. References the MedStar Managed Care Matrix and on-line Handbook as necessary. Obtains insurance referrals and pre-authorizations. Submits all referral information to necessary providers, as appropriate.
    Assists with pre-authorizations of hospital admissions, procedures, medications and medical equipment.
  • Maintains ongoing communication with insurance companies to determine eligibility of benefits, deductible status, and to obtain precertification for office-based and other procedures. Educates and informs patients and families regarding verification status and issues related to deductibles, co-payments and balances.
    Responds to hospital staff and/or patient inquiries regarding referrals, authorizations and scheduling in an efficient manner
  • Registration
    Will search the Enterprise Access Directory (EAD) to establish if the patient is new or existing. Follows guidelines to avoid duplicate medical record assignment.
    Obtains and/or verifies complete demographic and insurance information from patient. Accurately enters complete demographics, insurance information and Financial Status Classification (FSC) / Hospital Patient Accounting Plan Code assignment into the approved organization electronic scheduling and billing systems.
  • re-certification/Authorization & Billing
    Is responsible for resolving all outstanding Alerts on pending appointments within 48 hours of the scheduled appointment, to minimally include:
    Missing Referral
    Missing Pre-certification/Authorization
    Self Pay Accounts
    Eligibility Verification
    Missing Demographic/Insurance Information
  • MedStar and/or Georgetown University Hospital specific requirements
    Enters all relevant data, linking to the appropriate appointment/visit and ensures all required data elements are captured.
    Ensures all relevant data is entered into the Open Referrals Module, links data to the appropriate appointment / visit and enters the required data elements to ensure that accurate billing information is submitted to the . appropriate insurance carrier.
    Obtains any missing pre-certification or authorization numbers and enters into the appropriate field in the Appointment Data Form (ADF).
  • Establishes if the appointment needs to be rescheduled due to missing Referral or Authorization number. Works with departmental supervisor and/or clinician to determine medical necessity and if the appointment can be rescheduled. If appropriate, notifies the patient that the appointment needs to be rescheduled due to missing Referral/Pre-certification/Authorization
  • Reviews patient accounts with self-pay status. Confirms that patients understand the need to make payment on outstanding balances. Reviews rejected accounts to provide updated information to Physicians’ Unified Billing Service (PUBS) and relays appropriate information regarding denied claims to patients when necessary.
    Where appropriate and within GUH guidelines, ensures collection of pre-payments/deposits due from the patient prior to service for elective cases and prior to the procedure for add-on cases.
  • Reviews encounter forms to ensure appropriate data is being collected according to GUH guidelines. Performs coding and error resolution.
    Where appropriate, reconciles operative log report to ensure all procedure fees have been submitted to PUBS. Reconciles Admissions, Discharges and Transfers (ADT) reports to ensure all inpatient visits have been submitted to PUBS.
    Completes daily deposit by completing Official Receipts and Journal Vouchers for processing payments. Maintains deposit logs and records. Researches and resolves any deposit discrepancies.
    At the end of each day or session, batches encounter forms, prepares Batch Entry Form and Batch Control Log to be sent to PUBS.
  • Compiles and runs the Missing Charge Report each month and assists Administrator with reconciliation of missing charges. Performs quality audits as requested.
    Serves as liaison to PUBS and Patient Financial Clearance Unit (PFCU). Reviews rejection reports, ensures that corrective action is taken on all denied charges and that all charge sheets are resubmitted to PUBS for processing.
    Provides cross-coverage to Front Desk Check-in / Check-out position. Assists with payment and billing questions.
  • Scheduling
    Obtains basic clinical information from patients/callers to determine the appropriate appointment type and provider to which the appointment should be booked.
  • Identifies patient’s insurance, ascertains GPG and GUH contract participation status (Par vs. Non-Par) and communicates contract participation status to patient.
    Determines referral requirements, creates Referral in the approved organization electronic scheduling and billing system and links to appointment or updates ADF with Authorization / Pre-Certification number as appropriate.
  • Schedules patient follow-up appointments using the approved organization electronic scheduling and billing system, entering all required data elements as dictated by the GPG, GUH and departmental policies and procedures.
    Communicates referral requirements, patient’s financial responsibility and other pre-appointment information, as appropriate, including necessary procedure/examination preparations, e.g. NPO after midnight, according to departmental policies and procedures.
  • Answers incoming calls for practice and provides information regarding services, referrals, etc. Using standard forms or Electronic Health Record (EHR) system, records messages from patients, referring physicians, pharmacies, and other clinical areas. Communicates with physicians and nurses.
    Prints and distributes provider schedules to clinical team/management/administration as appropriate.
  • Medical Records
    Adhering to GPG and departmental policies and procedures, will access a patient’s medical record / electronic health record (MR/EHR), for work related activities only, to complete proper patient documentation in the health record or to view needed information in the patient chart as necessitated by job role or function. Adheres to most current work flows or processes developed within GPG or specific Practice.
    Appropriately and accurately scans and indexes documents, using correct naming conventions, into patient EHR.
  • Office Maintenance
    Maintains and utilizes all office equipment such as computers, fax machines, telephones, etc. according to manufacturer’s recommendations.
    Maintains competency in all electronic systems required for job functions.
  • Keeps personal work space neat, clean and free of debris at all times. Communicates building and facility issues or concerns to the appropriate housekeeping staff for resolution.
    Reports computer malfunctions, software issues and/or problems to the Help Desk or appropriate staff.
  • Observes Joint Commission (JC) standards, Patient Safety initiatives, Patient Rights, and Health Insurance Portability and Accountability Act (HIPAA) Privacy standards
    Follows care, documentation and cleanliness standards in the performance of job duties;
    Completes in-services and education on a timely basis;
  • Is focused on patient safety during performance of duties and improves or makes corrections when safety issues arise; notifies department manager, as required;
    Interacts with other team members both on the unit and in other units in an appropriate and proactive way to benefit the patient;
    Observes proper elevator etiquette and courtesy: smiles and speaks to patients and visitors, does not discuss patient care and keeps voice low, gives right-of-way to patients and visitors;
  • Performs other duties and responsibilities that are appropriate to the position and area. The above responsibilities are a general description of the level and nature of the work assigned to this classification and is not to be considered as all inclusive.


    • Minimum Qualifications
    Education

    • Associate’s degree required

    experience

    • 3-4 years Experience in a medical/clinical office required and
    • Previous experience with computerized scheduling and registration systems required
    • Previous experience with an electronic health record system (especially GE centricity clinical or ARIA) preferred

    Licenses and Certifications

    • N/A

    Knowledge, Skills, and Abilities

    • Excellent interpersonal communication and customer service skills, and good telephone etiquette.
    • Knowledge of medical terminology.
    • Effective oral and written communication skills.
    • Ability to deal effectively and professionally with a variety of different individuals.
    • Ability to perform in a high-pressure environment.
    • Ability to organize and prioritize work.


    This position has a hiring range of $18.7 – $32.72


    MedStar Health is an Equal Opportunity (EO) Employer and assures equal opportunity for all applicants and employees. We hire people to work in different locations, and we comply with the federal, state and local laws governing each of those locations.

     

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