PAS PSO Prior Authorization Specialist III WMCG

Core Responsibilities and Essential Functions

Quality/Safety

• Works in conjunction with Insurance Verification Specialist to verify insurance eligibility, benefits, network status and creates pre-service liability estimate.
• Ensures accurate ICD, CPT codes and related medical records are submitted in the authorization request.
• Secures prior authorizations for scheduled and nonscheduled services.
• Acts as a liaison between the payer and clinic schedulers/medical support staff.
• Follows up on delayed or denied authorization requests and escalates for resolution.
• Creates detailed documentation and maintains/stores the authorization paper/electronic trail.
• May work in the work queues to resolve claims denials related to the prior authorization.
• Documents thorough explanatory notes on patient accounts, concerning any non-routine circumstances, clarifying special billing processes.
• Maintains a working knowledge of available information system capabilities and performs all system applications that are required.
• Understands and applies WHS philosophy and objectives, and PAS policies and procedures, as related to assigned duties.
• Maintains confidentiality of patient information, in accordance with WHS policy and HIPPA regulations.
• Consistently demonstrates the ability to organize work, recognizes and establishes appropriate work priorities, and completes work in a productive manner, without creating backlogs.
• Maintains proficiency in data entry skills.
• Assists physicians and their office staff to expedite scheduling, pre-admission, Medicaid screening and pre-certifications on all accounts.
• Resolves errors and applicable Claim, DNB and Patient Work Queues.

Budget/Financial

• Attempts to collect the estimated self-pay balance of all inpatient, outpatient and ER accounts, at the earliest possible collection control point.
• Monitors in-house accounts and attempts to make financial arrangements with guarantors for payment of their self-pay balances in full and prior to discharge.
• Completes financial evaluation forms to document guarantors' income, expenses, assets and liabilities.
• Identifies those patients without adequate insurance coverage and determines potential eligibility for financial assistance programs (namely Medicaid).
• Maintains a list of health care financial assistance programs and the eligibility requirements for each program.
• Contacts scheduled patients at home to obtain pre-admission information, explain financial policies, estimate self-pay balances, and obtain a promise to pay on or before admission/registration.
• Interviews all inpatients and select (self-pay) outpatients at time of registration, or at least within 24 hours of admission, to verify complete insurance and financial information, explain financial policies, and collect the estimated self-pay balance.
• Documents concise and understandable notes regarding all self-pay account collection activity, as well as each patient or guarantor interaction.
• Coordinates financial counseling activities with Admitting, Outpatient Registration, Emergency Registration, Utilization Review, Nursing, Social Services, and Patient Financial Services.
• Verifies insurance coverage and benefits.
• Exceeds monthly quota on a consistent basis.
• Identifies and resolves Payor Denials as indicated.

Customer Service

• Greets all guest with a positive and professional attitude.
• Receives patients valuables for safekeeping in the hospital safe.
• Answers incoming phone calls and follows through with requests made.
• Maintains courteous and cooperative working relationships with WHS management, patients, physicians, other professional contacts, and the general public.
• Presents a well-groomed and professional image in coordination with dept/hospital dress codes.

General

• Observes work hours and provides proper notice of absences, tardies work schedule changes.
• Attends select departmental meetings at the request of WHS Management.
• Completes monthly, quarterly, and annual mandatory training as required.
• PAS III Team members serve as preceptors and mentors and as such must maintain a registration accuracy rate or higher in the past 12 months, maintain minimum productivity requirements, have no corrective disciplinary action during the past twelve (12) months, and be willing and able to function as a preceptor in the orientation of new patient access personnel and students.
• Maintain required certifications by obtaining necessary CEUs and submitting timely to certifying board.