Jones Memorial Hospital
Referral & Prior Authorization Specialist
Jones Memorial Hospital, Wellsville, New York, United States, 14895
STATEMENT OF PURPOSE:
This position assesses all aspects of patient financial account management for all patient visits and is accountable for coordinating all activities necessary to financially secure payment. The role involves in-depth communication, collaboration, and follow-up with patients, families, third-party payers, governmental agencies, employers, and case management to secure potential benefits, including financial assistance. The position is accountable for planning, execution, appeals, and efficient follow-through on all aspects of the prior authorization process. In addition, the incumbent is responsible for monitoring their own performance on assigned tasks and adheres to approved protocols for working referrals and prior authorizations. The position is self-directed and must make complex decisions independently. May train other support staff as assigned.
MAJOR TASKS, DUTIES AND RESPONSIBILITIES:
Maintains a clean, safe, and orderly work area; operates and makes minor adjustments or repairs to business machines as needed. Communicates regularly and works collaboratively with the Supervisor to address operational issues within the department. Maintains patient confidentiality at all times. Presents a positive and professional attitude in all interactions. Works closely with associates to support departmental efficiency and provides assistance to registration as needed. Communicates with the Supervisor regarding operational issues and contributes to process improvement efforts for greater efficiency. Reviews inpatient, observation, same-day care (SDC), and swing-bed visits for insurance accuracy using the hospital system and third-party payer systems; updates the billing department as appropriate and reports inaccuracies or trends to the Supervisor. Verifies that the Veterans Administration (VA) has been notified for all applicable emergency department patients. Obtains pre-certifications and/or completes required notifications (within the 24-48-hour guideline) for all observation, inpatient, and swing-bed admissions. Monitors current admissions, observations, and swing-bed cases to ensure eligibility and authorization requirements are met; escalates to Case Management when a medical assessment is needed. Assists patients with Financial Subsidy Applications; monitors applications for potential Medicaid eligibility and refers to the Patient Financial Counselor as appropriate. Manages department referrals, serving as liaison, appointment coordinator, and patient advocate between referring offices, specialists, and patients to assist in coordinating scheduled visits and procedures. Incorporates all incoming referrals to the department using Epic referral work queues. Works independently with minimal supervision while maintaining accuracy, professionalism, and adherence to established protocols. Performs other related duties as requested within the scope of abilities and hospital policy. EDUCATION:
High School Diploma or equivalent required. Associate degree in Business, Healthcare Administration, or related field preferred. EXPERIENCE:
Two (2) years of experience in healthcare billing, patient financial services, registration, or insurance authorization required. Experience with Epic or other electronic health record systems preferred. Prior authorization or hospital registration experience strongly preferred. CONTACTS:
Frequent contact with patients, families, physicians, third-party payers, and hospital personnel in multiple departments. PHYSICAL DEMANDS:
Requires frequent sitting, standing, and walking. Manual dexterity for computer and office equipment use. Occasional lifting or carrying of materials up to 25 pounds.
This position assesses all aspects of patient financial account management for all patient visits and is accountable for coordinating all activities necessary to financially secure payment. The role involves in-depth communication, collaboration, and follow-up with patients, families, third-party payers, governmental agencies, employers, and case management to secure potential benefits, including financial assistance. The position is accountable for planning, execution, appeals, and efficient follow-through on all aspects of the prior authorization process. In addition, the incumbent is responsible for monitoring their own performance on assigned tasks and adheres to approved protocols for working referrals and prior authorizations. The position is self-directed and must make complex decisions independently. May train other support staff as assigned.
MAJOR TASKS, DUTIES AND RESPONSIBILITIES:
Maintains a clean, safe, and orderly work area; operates and makes minor adjustments or repairs to business machines as needed. Communicates regularly and works collaboratively with the Supervisor to address operational issues within the department. Maintains patient confidentiality at all times. Presents a positive and professional attitude in all interactions. Works closely with associates to support departmental efficiency and provides assistance to registration as needed. Communicates with the Supervisor regarding operational issues and contributes to process improvement efforts for greater efficiency. Reviews inpatient, observation, same-day care (SDC), and swing-bed visits for insurance accuracy using the hospital system and third-party payer systems; updates the billing department as appropriate and reports inaccuracies or trends to the Supervisor. Verifies that the Veterans Administration (VA) has been notified for all applicable emergency department patients. Obtains pre-certifications and/or completes required notifications (within the 24-48-hour guideline) for all observation, inpatient, and swing-bed admissions. Monitors current admissions, observations, and swing-bed cases to ensure eligibility and authorization requirements are met; escalates to Case Management when a medical assessment is needed. Assists patients with Financial Subsidy Applications; monitors applications for potential Medicaid eligibility and refers to the Patient Financial Counselor as appropriate. Manages department referrals, serving as liaison, appointment coordinator, and patient advocate between referring offices, specialists, and patients to assist in coordinating scheduled visits and procedures. Incorporates all incoming referrals to the department using Epic referral work queues. Works independently with minimal supervision while maintaining accuracy, professionalism, and adherence to established protocols. Performs other related duties as requested within the scope of abilities and hospital policy. EDUCATION:
High School Diploma or equivalent required. Associate degree in Business, Healthcare Administration, or related field preferred. EXPERIENCE:
Two (2) years of experience in healthcare billing, patient financial services, registration, or insurance authorization required. Experience with Epic or other electronic health record systems preferred. Prior authorization or hospital registration experience strongly preferred. CONTACTS:
Frequent contact with patients, families, physicians, third-party payers, and hospital personnel in multiple departments. PHYSICAL DEMANDS:
Requires frequent sitting, standing, and walking. Manual dexterity for computer and office equipment use. Occasional lifting or carrying of materials up to 25 pounds.