Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates.

The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time).

Pay Range:

Scheduled Weekly Hours:

Position Overview

Call Center Authorization/Quality Specialist

JOB CODE:50847

FLSA Exemption Status:Non-Exempt

SUMMARY (BASIC PURPOSE OF THE JOB)

MINIMUM REQUIREMENTS

Education: High school diploma or GED.

Experience: Five years of experience in patient scheduling or in a medical office role working with patient insurance. Experience in insurance verification and authorization preferred.

Other Credentials:

Knowledge and Skills:Working knowledge of medical insurance plans. Proficiency in working with payors on-line portals, as well as Experian and Navinet preferred. Basic knowledge of medical terminology and diagnosis. Possesses strong skills in patient relations, pre-registration, scheduling, pre-certification, and auditing of all scheduled outpatient accounts.

Special Training:Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to prepare and interpret bar graphs. Ability to utilize common sense understanding in order to carry out written, oral or diagrammed instructions.

Mental, Behavioral and Emotional Abilities:Ability to deal with problems involving several known variables in situations of a routine nature. Ability to effectively communicate information and respond to questions in person-to-person and small group situations with customers, clients, general public and other employees of the organization.

Usual Work Day:8 Hours  

ESSENTIAL FUNCTIONS

• Uses knowledge and skills of pre-registration scheduling requirements and applies them during chart review. Reviews all required information to ensure chart is complete.
• Performs chart review to identify if variation from quality registrations exists. Determines the need for process improvement. Identifies concerns and makes recommendations for review to improve processes.
• Communicates findings as appropriate to department management involved. Reports discrepancies to supervisor or manager to ensure corrective action is taken in a timely manner.
• Maintains complete knowledge of the pre-registration/scheduling system and department operational procedures and training guidelines to identify and audit charts for accurate demographic, diagnosis, and insurance information for all scheduled tests.
• Secures insurance authorizations and pre-certifications for outpatient services. Verifies pre-certification to ensure appropriate reimbursement.
• Maintains proper communication skills with physician offices to obtain needed information for authorizations. Obtains and reviews physician orders for medically necessity coverage requirements.
• Assists with development and implementation of new or improved processes. Maintains up to date knowledge with Insurance matrix, pre-registration and scheduling compliance, insurance applications, and other systems utilized by Central Scheduling.
• Possesses proficiency with all insurance plans and payor codes. Identifies payment source and secures all information required to insure a billable and collectable account and avoid penalties or denials prior to the bill dropping.
• Maintains thorough understanding of payor requirements for authorization, pre-authorization, and referrals. Performs verification of benefits either electronically or by telephone according to department procedures and guidelines.
• Identifies and obtains required precertification, authorizations and referrals and audits all information in the appropriate scheduling and billing system.
• Possesses ability to understand and use audit reports for missing vital billing information. Reviews coordination of benefits and Medicare secondary payor guidelines to determine primary and secondary payer status.
• Assists with development and implementation of new or improved processes. Maintains knowledge and is proficient with On-Base, Gaffey, all insurance applications including Experian, Navinet, Cerner pre-registration functions, and other systems utilized by Central Scheduling/Pre-certification functions.
• Provides ongoing performance feedback, addresses problems, and assists with training of new employees. Verifies and documents competency and identifies and suggests ways to develop skills.
• Communicates new insurance rules, changes in policies, procedures and regulations as needed. Monitors compliance with regulatory, licensing, and accreditation standards.
• Facilitates quality improvement by reporting problems, concerns, and opportunities for increased revenue and decreased denials. Contacts patients prior to scheduled visit with inactive insurance coverage to obtain updated insurance information.
• Works closely with other hospital staff, providers, and patients to resolve any issues with missing or incomplete authorizations and pre-registration to provide a smooth process.
• Performs any other related duties as required or assigned.

PHYSICAL DEMANDS AND WORK ENVIRONMENT

Frequent physical demands include: Sitting , Standing , Walking , Keyboard use/repetitive motion

Occasional physical demands include:

Continuous physical demands include:

Lifting Floor to Waist 15 lbs. Lifting Waist Level and Above 10 lbs.

Sensory Requirements include: Very Accurate 20/40, Near Vision, Accurate Far Vision, Minimal Color Discrimination, Minimal Depth Perception, Accurate Hearing

Anticipated Occupational Exposure Risks Include the following: N/A

This position is eligible for the following benefits:

• Medical Plan

• Prescription drug coverage & In-House Employee Pharmacy

• Dental Plan

• Vision Plan

• Flexible Spending Account (FSA)

- Healthcare FSA

- Dependent Care FSA

• Retirement Savings and Investment Plan

• Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance

• Supplemental Group Term Life & Accidental Death & Dismemberment Insurance

• Disability Benefits – Long Term Disability (LTD)

• Disability Benefits – Short Term Disability (STD)

• Employee Assistance Program

• Commuter Transit

• Commuter Parking

• Supplemental Life Insurance

- Voluntary Life Spouse

- Voluntary Life Employee

- Voluntary Life Child

• Voluntary Legal Services

• Voluntary Accident, Critical Illness and Hospital Indemnity Insurance

• Voluntary Identity Theft Insurance