Insurance Specialist - Detroit, MI
Under general supervision, identifies and determines in accordance with established policies and procedures the accuracy and completeness of financial, insurance and/or demographic information for patients receiving care HFHS. Accountable and responsible for all pre-admissions, admissions, and specified scheduled outpatient services rendered at HFHS. Investigates and reviews the accuracy and completeness of insurance information upon pre-admission and/or admission to ensure account is secure prior to discharge. Obtains benefit, co-pay, deductible, and co-insurance information. Verifies insurance eligibility and benefit information and confirms that all insurance requirements are met, including but not limited to referrals and authorizations. Resolves problem accounts to determine primary insurance and/or COB information.
PRINCIPLE DUTIES AND RESPONSIBILITIES:
A variety of functions and responsibilities related to insurance verification and identifying authorization requirements prior to and/or after discharge of patient, which includes:
- Research and review all insurance plans and confirms patient benefit eligibility, including patient liabilities, clauses, riders, and secondary payor information (coordination of benefits) via internal and external resources including contacting payor representatives as needed.
- Reviews and interprets insurance group pre-certification requirements. Ensures proper pre-authorizations have been obtained. Executes on-line operations for specific payors to complete the pre-certification process. Communicates data to HFHS Utilization Management Department for further medical review.
- Resolves discrepancies with the patient and/or family members, employers and insurance companies to assist in obtaining insurance information. Interviews patients and/or family members; advises patient with regards to next steps or processes for securing financial coverage. Reviews and analyzes third party COB screen prior to billing to prevent claims rejection. Works with patient or family member regarding outstanding COB issues.
- Reviews, analyzes and corrects COB discrepancies and other related issues to ensure the integrity of the insurance information is accurate prior to discharge.
- Handles insurance questions and/or obtains information from various HFHS areas including but not limited to clinics, physicians, patients, attorneys, employers and outside agencies via telephone or mail.
- Prepare and ensures account for accuracy in preparation for billing to third party payors utilizing several different arenas within HFHS computer system as well as other on line systems.
- Obtains referral from referring physician office, prior to admission, as required by the payor.
- Maintains status of all accounts pending verification reviews, utilizing applicable work queues, and takes appropriate action to resolve accounts.
- Represents HFHS to external agencies on issues involving workers compensation, motor vehicle accidents and/or third party liability admissions and issues pertaining to financial policies and procedures.
- Performs functions necessary to secure referrals/authorizations on applicable encounters, maintaining an appropriate lead-time as established by departmental guidelines.
- Responsible for referring accounts to the HFHS funding source vendor when an insurance cannot otherwise be secured.
Provides World Class Service Excellence to patients:
- Warm patient greeting and closing. (AIDET)
- Service Recovery (HEART)
- Adheres to Chief First Impressions Officer (CFIO) standards.
- Maintains Front Desk and Lobby Appearances according to policy.
- High school diploma or GED equivalent is required.
- Two (2) years of experience related to healthcare insurance eligibility, insurance verification or insurance billing in a hospital/medical office setting.
- Knowledge of various insurance coverage, COB rules of priority and processing procedures.
- Insurance payor systems experience required.
- EPIC training/experience preferred.
- ICD-10 medical terminology experience preferred.
- Ability to adjust to new technologies as introduced.
- Strong computer skills and working knowledge of Microsoft Office products.
- Ability to perform a variety of tasks in a fast-paced environment with frequent Interruptions.
Equal Employment Opportunity/Affirmative Action Employer