Job Description

Under the supervision of the Precertification Supervisor, is responsible for obtaining precertification and verification of benefits with all insurance carriers for inpatient admissions, outpatient and day surgeries, GI procedures, radiology services, sleep studies and/or echocardiograms. Financially secures each account well in advance and escalates financial clearance concerns through prompt and closed-loop communication. Collaborates and reviews financial clearance data with the Precertification Supervisor and Manager to ensure proper authorization for all services.

PRINCIPAL DUTIES AND ESSENTIAL FUNCTIONS:

• Contacts insurance companies to obtain verification of insurance, eligibility, and level of benefits. Enters benefit information into hospital computer systems.
• Contacts patients, when necessary, for updates of financial and demographic information. Enters all data into hospital computer systems.
• Obtains financial data from a variety of sources including both in-state and out-of-state payers. Utilizes computer systems, payer eligibility sites & phone outreach.
• Arranges for coordination of benefits when more than one insurance carrier is involved.
• Updates financial/insurance plan codes within hospital computer systems according to eligibility responses.
• Seeks clinical approval of admission (precertification) for surgeries, admissions, procedures, imaging and all other in-scope services. Enters precertification information and proper documentation into hospital computer systems.
• Identifies procedures & services that are not covered services by individual insurance policies. Refers all identified financial risk concerns to the department, Patient Access leadership for immediate review and resolution.
• Collaborates with Financial Coordination colleagues regarding patients with identified financial risk concerns for resolution prior to services being rendered. Suggests postponement of elective services until financial arrangements are in place.
• Obtains all applicable clinical documentation when required by insurance payers for elective services and submits information to payers within a timely manner.
• Closely follow case statuses and communicates and/or documents pending and approved statuses within a timely manner.
• Immediately identifies denied claims and works closely with department leaders, coordinators and clinical team members toward their appeal and peer to peer workflow.
• Monitors their productivity and quality of workflow directly, reaching days out, productivity, and quality review goals.
• Acts as a resource to other departments of the hospital regarding precertification policies and resolution of accounts.
• Communicates clearly to Tufts MC team members and leadership status of financially at risk cases and resolution steps. Closely monitors at risk cases and provide timely updates.
• Maintains collaborative, team relationships with peers and colleagues in order to effectively contribute to the working group’s achievement of goals, and to help foster a positive work environment.
• Works closely with Case Management and Admitting colleagues to confirm level of care changes, particularly for unplanned or urgent admissions, and communicate level of care upgrades or downgrades with payers within a timely manner.
• Learns workflow changes and updates as they occur in real-time and maintains an openness to adopt updated workflows.
• Assists in the training and shadowing of new team members.
• Performs other similar and related duties as required or directed

Qualifications

JOB KNOWLEDGE AND SKILLS:

• Thorough knowledge of medical terminology.
• Thorough working knowledge of ICD-10 and CPT coding.
• Thorough working knowledge of payer precertification requirements and in-network and out-of-network payers.
• Thorough working knowledge and willingness to learn computer systems.
• Strong verbal and written communication skills. Must demonstrate a patient service focus.
• Excellent organizational skills and ability to prioritize work assignments. Ability to respond effectively to changing priorities and work processes.
• Ability to work independently and also participate in teams within the department and Tufts MC.

EDUCATION:

• Level of knowledge generally acquired through completion of an Associates degree or equivalent experience.

EXPERIENCE:

• Two to three years related experience in a hospital, physician office or financial setting.
• An equivalent combination of education and experience which provides proficiency in the areas of responsibility listed above may be substituted for the above education and experience requirements

WORKING CONDITIONS/PHYSICAL DEMANDS:

• Works in a normal office environment with little exposure to hazardous or unpleasant conditions.
• Some mental pressure due to time constraints.
• Interacts daily over the phone, email and online portals through correspondence with payers. Establishes and maintains working relationships with insurance companies to facilitate financial clearance workflow of Tufts MC services.
• Interacts with patients regarding issues dealing with confidential medical and financial information.
• Daily contact with clinicians, administrative coordinators, department leaders, Patient Access colleagues, Patient Access leadership and other personnel from various departments.

Additional Information

All your information will be kept confidential according to EEO guidelines.

AMERICANS WITH DISABILITIES STATEMENT:

Must be able to perform all essential functions of this position with reasonable accommodation if disabled.

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed, as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. Tufts Medical Center reserves the right to modify position duties at any time, to reflect process improvements and business necessity.

COVID-19 POLICY:

Please note that effective October 1, 2021, as a condition of employment at Tufts Medical Center, all employees and new hires must have received their complete dose of the COVID-19 vaccine, unless they have been granted an exemption.