Patient Insurance Benefit Specialist

Position Summary

Evaluates patients potential financial liability prior to and after medical services have been rendered. This includes working with patients and their families to evaluate financial data and determine ability to pay under all payors, negotiating payment arrangements and administering hospital and state financial assistance programs.

Essential Duties

1. Evaluates and communicates patients potential financial liability directly to the patient prior to medical services being rendered based on insurance verification data and medical cost estimates. Negotiates collection deposits of estimated co-insurance, co-pay and deductible amounts.
2. Provides financial counseling by telephone, electronic/standard mail or face-to-face to patients/guarantors to ensure collectability of patient balances and/or accounts in compliance with federal and state laws regarding debt collection and hospital billing and collection policies. This includes securing patient payments by negotiating payment plans or arranging alternative settlement agreements.
3. Administers hospital financial assistance policies and the Colorado Indigent Care Program (CICP). Audits and adjusts all charity accounts monthly. Interprets individual, self-employed and business financial statements to accurately rate a patient using the guidelines of the charitable programs.
4. Evaluates patient financial applications for Colorado Medicaid eligibility. Assists patients with Colorado Medicaid application process.
5. Maintains ability to read and comprehend all payors claims adjudication vouchers. Utilizes vouchers in order to perform comprehensive account audits as necessary on self-pay balance disputes, processing of patient refunds, payment transfers and adjustments in accordance with PBO policy.
6. Handles all patient questions and concerns with regard to the processing of patient insurance claims and financial assistance eligibility. Performs self-pay and bad debt collection follow-up as assigned and in accordance with PFS policy.
7. Serve as the PFS Customer Service Representative to the Patient Financial Services Department. Providing excellent customer service to patients, co-workers, and clinical staff. Greets customers on the telephone or in person, assesses needs and provides information and /or services requested. Directs patients to appropriate departments as needed.
8. Performs Insurance verifications. Includes obtaining and documenting covered and non-covered benefits, plan type, copayments, co-insurance, out of pocket, and deductible amounts and determining contract and benefit eligibility. Contact insurance companies as needed.
9. Reviews and may complete authorizations and referral requests. Communicates with utilization management department as necessary to ensure that services are authorized.
10. Submit billings to pharmaceutical copay assistance programs for reimbursement of claims.
11. Maintains a current and thorough working knowledge of third party payors processing in regards to medical management policy, provider contractual obligations, patient benefit levels, and payor specific insurance terminology.
12. Maintains appropriate level of knowledge regarding NJH clinical operations.

Other Duties

1. Maintains appropriate level of expertise with the HIS, EMR, eligibility software, scheduling software, scanning software, merchant software, and vendor systems.
2. Establishes and maintains effective working relationships and customer service skills. Including patients, clients, co-workers, third party payors, NJHs early out pre-collections (EOVC) and collection agency. Actively participates in team and departmental meetings by sharing ideas for improved work processes in PFS.
3. Communicates regularly with Supervisor or Manager regarding high-risk accounts. Identifies and refers problematic workflow trends to Supervisor for evaluation and solution.
4. Provides supervisor with weekly productivity statistics and reports workload fluctuations (backlog or shortages) in a timely manner.

Competencies

1. Adaptability: Maintaining effectiveness when experiencing major changes in work responsibilities or environment; adjusting effectively to work within new work structures, processes, requirements, or cultures.
2. Attention to Detail: Accomplishing tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time. Setting high standards of performance for self and others; assuming responsibility and accountability for successfully completing assignments or tasks; self-imposing standards of excellence rather than having standards imposed.
3. Building Trust: Interacting with others in a way that gives them confidence in ones intentions and those of the organization.
4. Business Acumen: Using economic, financial, market and industry data to understand and improve business results; using ones understanding of major business functions, industry trends, and own organizations position to contribute to effective business strategies and tactics.
5. Collaboration/Teamwork: Cooperates with others to accomplish common goals; works with employees within and across his/her department to achieve shared goals; treats others with dignity and respect and maintains a friendly demeanor; values the contributions of others.
6. Customer Focus: Ensuring that the customer perspective is a driving force behind business decisions and activities; crafting and implementing service practices that meet customers and own organizations needs.
7. Initiative: Taking prompt action to accomplish objectives; taking action to achieve goals beyond what is required; being proactive.

Supervisory or Managerial Responsibility

None

Travel

None

Core Values

1. Be available to work as scheduled and report to work on time.
2. Be willing to accept supervision and work well with others.
3. Be well groomed, appropriately for your role and wear ID Badge visibly.
4. Be in compliance with all departmental and institutional policies, the Employee Handbook, Code of Conduct and completes NetLearning by due date annually.
5. Fosters an inclusive workplace where diversity and individual differences are valued and leveraged to achieve the vision and mission of the institution.
6. Adheres to safe working practices and at all times follows all institutional and departmental safety policies and procedures.
7. Wears appropriate PPE as outlined by the infection control policies and procedures.
8. Demonstrates compliance with all state, federal and all other regulatory agency requirements.

Minimum Qualifications

1. Education: Associates degree is required.
2. Work Experience: A minimum of 2 years experience in financial counseling, patient financial services or insurance billing in a healthcare or health insurance environment in any aspect of the revenue cycle process required.
3. Special Training, Certification or Licensure: None