Senior Benefit Verification Specialist

Job Description

The Shared Services Center - Fort Smith provides business office support functions like billing, insurance follow-up, call center customer service, data entry and more for hospitals and healthcare providers.

The Senior Benefit Verification Specialist verifies Outpatient (OP), Inpatient (IP), and Observation (OBS) benefit coverage, performs medical necessity verification, authorization requirements, and initiations for admission initiates, obtains, and/or validates all necessary referrals, notifications, pre-certification, and/or authorizations for scheduled services, and determines estimated patient financial responsibility for scheduled OP services. This position will support our Shared Services Center and client hospitals around the country for a wide variety of payors, service lines, and patient types by providing top-notch support to the entire revenue cycle.

Essential Duties and Responsibilities: (List in order of importance or percentage of time spent on the particular responsibility. High to Low)

* Verify insurance eligibility, benefits, notification/authorization/precertification/referral guidelines, and create patient estimated portions via estimated tool for OP diagnostic, OBS, and IP services, as applicable, following established guidelines and accurately notating all actions performed in the applicable host system(s). (40%)
* Identify pre-authorizations/pre-certifications/referrals that are not valid and/or have outstanding documentation requests, required follow-up action, and/or other payor issues, and contact the appropriate party (i.e. payor, ordering office, and/or facility) to verify/validate requirements to ensure accuracy and avoid potential denials. Further, contacting the ordering physician's office, if necessary, to have the pre-authorization updated, resubmitted, or withdrawn. (20%)
* Verifies that documents are valid for scheduled service(s) being performed, date of service, and the correct facility. (10%)
* Use of web applications and documentation provided by the physician's office to determine if the scheduled service is medically necessary, based on payor guidelines by CMS and commercial payors, and notifies physician office or appropriate department of any tests that do not meet medical necessity guidelines. (10%)
* Use advanced knowledge of Pre-Arrival functions to lead process improvement initiatives and workgroup(s). (10%)
* Performs all other duties, as assigned or requested, while adhering to strict deadlines. (10%)

Qualifications:

Required Education: High School Diploma or Equivalent

Required Experience: Minimum 2 years within Benefit Verification Department and/or 2 years of medical office, healthcare facility, or other Revenue Cycle experience

Required License/Registration/Certification: Certified Healthcare Access Associate (CHAA)

Preferred License/Registration/Certification: Certified Professional Coder (CPC), or Certified Healthcare Access Manager (CHAM)

Reasoning Ability:

Ability to define problems, collect data, establish facts and draw valid conclusions. Ability to interpret an extensive variety of payer requirements and medical necessity responses.

Computer Skills Required:

To perform this job successfully, an individual should have knowledge of applicable host systems, web applications, scanning and telephony technology, ancillary applications, and payor web applications. Work with the technology necessary to complete the job effectively.