The Insurance Verification teammate is responsible for ensuring scheduled procedures are on the patient's insurance-covered list and/or the patient meets self-pay criteria. The Insurance Verification teammate will be responsible for verifying insurance coverage, eligibility, and benefits, obtaining authorizations and pre-certs as required by the individual insurance company. The teammate will verify that all scheduled procedures are on the ASC procedure listing. The Insurance Verifier will be familiar with and understand Medicare, Medicaid, other government payers, and Commercial and HMO/PPO Payers’ guidelines and principles.

The Insurance Verification teammate will be responsible for calculating co-insurance estimates per the payer contract as applicable and amounts due from self-pay patients are according to the center’s self-pay guidelines, Policies, and Procedures. The teammate will enter the verification, eligibility, and benefits information in the patient accounting system including the date, time, and method used to obtain the verification/eligibility information for each patient. The documentation will include the amount expected from the patient on or before the date of service.

The Insurance Verification Clerk is responsible for communicating insurance benefit information and financial responsibility to each patient during a Pre-Registration Financial Orientation call prior to the date of service. The verifier is responsible for verifying the patient demographic and insurance information along with subscriber information and secondary insurance as applicable during the Pre-Registration Financial Orientation call.

PASTEUR PLAZA SURGERY CENTER strives to provide excellent customer service to all patients and physicians by promptly, accurately, and efficiently verifying insurance, self-pay accounts, and notification to patients prior to the date of service.

Position Reports to Business Office Manager

Position Supervises: None

Degree of Supervision Provided to Position:

• Minimal and according to management guidance, must be self-directed and able to work independently.

Education, Experience, and Licensure:

• Associate degree or equivalent from a two-year college or technical school; or six months to one year experience in a medical office, hospital, outpatient surgery center, or related field; Computer experience, Excel, Word, Medical Applications; Self-starter, Good Phone etiquette.

Internal Relationship (Works closely with):

• As a representative of Pasteur Plaza Surgery Center, all comments, attitudes, actions, and behaviors have a direct effect on the Facility’s image and perceptions of quality service. Interaction with patients, families, physicians, referral sources, affiliating schools, visitors, volunteers, co-workers, supervisors, vendors, etc. must be in a manner that is friendly, supportive, courteous, respectful, cooperative, and professional. This behavior should promote an atmosphere of teamwork, which is congruent with Facility standards and guidelines to promote positive relations.

Job Requirements:

Skills and Abilities

Insurance Verification:

1. Verify that sufficient information is available for accurate verification and eligibility. This step may require direct contact with the physician’s office and/or the patient.
2. Determine if secondary insurance should be added to the patient account ensuring the appropriate payer is selected for Primary insurance.
3. Utilize the center’s selected vendor for claims and eligibility and/or individual payer websites to obtain eligibility, benefits, and/or pre-certs and authorization information.
4. Enter the patient’s Insurance information into the patient accounting system ensuring the selection is the appropriate payer and associated financial class. Ensure that the appropriate Electronic Billing number, Managed care network, and address are on the insurance profile.
5. When the patient's insurance Js is Out of Network notify the manager Immediately. Follow the Policies and Procedures when accepting Network payers.
6. PASTEUR PLAZA SURGERY CENTER's goal for each patient's insurance verification is complete and accurate. The insurance verifier will document the findings in the patient account and will contact the patient with either estimated co-insurance, co-pay, and or deductible amounts due on or before the date of service as applicable.
7. The Insurance Verifier will call each patient as part of center compliance with CMS Conditions for Coverage guidelines in contacting patients prior to the date of service to review, Physician Ownership, Advance Directives, and Patient Rights.

Authorization:

1. Obtain authorizations from insurance companies/physician offices. Ensure complete and accurate information is entered into the patient accounting system and the procedure scheduled, date of service, and facility name are on the authorization. Ensure the authorization has not expired.
2. Enter authorization into the patient accounting system. Include the name/CPT codes effective date of the authorized procedures.
3. Ensure high-cost Implant/supply or equipment rental Is included in the authorization.
4. Check Insurance company-approved procedure lists/medical policies. If a procedure is not payable, notify the patient If a patient wants to proceed, obtain a signature on Medicare ABN or another non-covered notification form.

Financial Orientation:

1. Calculate co-pay and estimated co-insurance due from patients per the individual payer contract and plan as applicable.
2. Acceptance of in-network benefits for out-of-network payers must be pre-approved by PASTEUR PLAZA SURGERY CENTER Compliance Dept.
3. Be familiar with individual payer guidelines and the process of collecting over-the-counter payments/deductibles/co-pay/co-insurance. Knowledge of payer contracts including Medicare.
4. Medicaid and other government contracts and guidelines and workmen's compensation fee schedule.
5. Contact the patient and communicate the center’s financial policy.

Clinical Quality:

1. Communicates patient information to assure confidentiality and continuity of care.
   1. Documents all patient information according to established standards of care, policies, and procedures.
   2. Discusses patient information with other health team members in an appropriate environment.
2. Interacts with all patients, families, visitors, and fellow employees in a mature, responsible manner to ensure a positive and professional facility environment.
   1. Displays a caring and responsive attitude and conducts all activities respecting patient, family, and employee rights and expectations.
   2. Maintains confidentiality of all facility and patient Information as required by facility policy.
3. Considers age-specific needs in communication.

Teamwork/Accountability/Integrity:

1. Utilizes time effectively.
2. Follows estabf1Shed facility policies and procedures regarding attendance.
   1. Maintains attendance according to guidelines and policy established by the facility.
   2. Provides notification for unscheduled absences or tardiness in accordance with established departmental procedures as noted by supervisor.
   3. Requests scheduled time off according to the procedure as noted by the supervisor.
3. Completes all documentation to ensure the availability of accurate and up-to-date information in accordance with established standards.
4. Adheres to established facility safety requirements and procedures to ensure a safe working environment.
   1. Demonstrates competent usage of proper body mechanics in all activities.
   2. Identifies potentially unsafe situations and notifies supervisor.
   3. Completes all Teammate/patient event and Variance documentation in a thorough and timely manner, as required by policy.
   4. Demonstrates a complete understanding of established emergency procedures for the facility.
   5. Practices infection control, standard precautions, and universal precautions as instructed or trained.
   6. Maintains work area and equipment in a neat, organized manner.
5. Completes appropriate financial management responsibilities.
   1. Provides input re: equipment needs/supply needs.
   2. Completes patient charges in accordance with facility procedure and per facility policy.
   3. Demonstrates sound cost containment techniques.
6. Assists with housekeeping tasks as necessary to provide a safe environment for patients, teammates, physicians, and guests.
7. Upholds and practices the principles and policies of the PASTEUR PLAZA SURGERY CENTER Compliance program.
8. Performs all other duties as assigned by management.

Continuous Improvement:

1. Attends staff meetings and demonstrates review of minutes for any meetings missed.
2. Participates in scheduled performance appraisals and demonstrates dedication to ongoing performance improvement.
3. Fosters a positive and professional facility environment by interacting with all persons IN A considerate, helpful, and courteous manner and by participating as a team member.
   1. Diffuses/resolves the conflict by appropriately communicating with those involved.
   2. Accepts constructive criticism and gives suggestions in a professional manner.
   3. Considers age-specific needs in communication.
4. Maintains dress and appearance according to standards as observed by management.
5. Demonstrates the safe operation of equipment and machinery and follows procedures for reporting and correcting an unsafe situation.
6. Strives to be professional, courteous, helpful, and cooperative.
7. Proficiency or Productivity Standards

ENVIRONMENTAL CONDITIONS:

Indoors in a climate-controlled environment. Patient care environment with potential exposure to unpleasant odors, to blood, and body fluids that may carry infection, infectious disease, and to chemical and electrical hazards.

PHYSICAL REQUIREMENTS:

Ability to answer the telephone; Ability to sit for long periods of time; Ability to lift 15 lbs.; Hand/finger agility necessary to typing and computer use; Good hearing, clear/articulate speech, and visual acuity.

MACHINES/EQUIPMENT USED:

All office machines including PCs, Copier, Fax, Phones, 10 Key, and Postage Meter