Eligibility Specialist

Compensation Disclaimer

Compensation for this role is based on a number of factors, including but not limited to experience, education, and other business and organizational considerations.

Department: ASAP BHO - Admitting/Registration

FTE: 1.00
Full Time
Shift: Days

Position Summary:
Perform pre-registration and registration functions for Ambulatory/Outpatient Operations area assigned;
verify insurance coverage eligibility and benefits;
verify required referrals and/or prior authorization are in place prior to visit;
contact patients for outdated or missing demographics;
professional and efficient phone call handling via telephone ACD system in a call center setting;
perform as first contact for Persons in Custody of Law Enforcement Agency (PICLEA) as they arrive for care;
screen patients for coverage and assist them in navigating their financial options including UNMH or other UNM Health Systems financial assistance, NM Medicaid, or other State and Federal Programs;
perform intake applications for State of NM Medicaid;
Ensure adherence to Hospitals and departmental policies and procedures. No patient care assignment.

Detailed responsibilities:
* PATIENT CARE - Assist patients in locating departments;
schedule and coordinate patient appointments;
refer patients and families to appropriate services and resources
* CUSTOMER SERVICE - Provide information and assistance to internal and external customers;
provide and ensure quality service and customer satisfaction
* DATA - Perform data entry and research using various hospital system programs
* DATA ENTRY - Enter various data into computer;
verify data, make corrections and ensure accuracy
* REGISTRATION - Interview patients and/or families to obtain demographic, financial information and signatures as required;
schedule new and follow-up appointments
* PRIOR AUTH/INSURANCE - Verify insurance coverage and benefits on patients needing an Auth;
provide notification ofadmission and obtain auth for emergency admits;
obtain authorizations for same day surgery, inpatient surgery, direct admits and any other pre scheduled stays or procedures. Provide all pertinent medical history/documentation for insurance companies and other payors in order to obtian an auth;
document Cerner with correct information;
Scan all documents concerning authorization and reimbursement into Siemens document imaging;
may collect down payments for and copays for procedures. Create Pre Admits in Cerner as appropriate
* PRIOR AUTHORIZATION - Complete pre-screening process for specialty clinic appointments for referral and/or prior auth
* FINANCIAL ASSISTANCE - Interview patients and complete the application process for State/Government programs;
maintain MOSAA certification with the State;
interview and approve patients for UNM Hospital charity and discount programs
* FINANCIAL ASSISTANCE - Refer self-pay patients for financial assistance;
make financial assistance appointments
* ELIGIBILITY - Determine and process eligibility for financial assistance (Including Medicaid, SCI, UNM Care, Commercial, Medicare, PHS/Indian Health Service, Salud, Self Pay)
* REFERRALS - Maintain a knowledge of community financial resources and refer patients appropriately (EMSA).
* TRAINING - Perform training with registration and admitting personnel to assure proper registration and knowledge of business practices to include financial assistance programs
* TRAINING - Perform outreach/training with clinical areas to ensure process flow remains tight and to maintain open communication
* CUSTOMER RELATIONS - Establish and maintain good rapport and effective working relationships with patients, visitors, physicians and Hospitals employees
* DEVELOPMENT - Enhance professional growth and development through participation in educational programs, reading current literature, attending in-services, meetings and workshops
* LIAISON - Perform as liaison between clinic staff, providers, and the insurance company or other payors to coordinate financial benefits/ coverage and prior authorizations
* CODING - Assign ICD9 or ICD10, CPT codes as required by insurance companies in order to obtain authorization for services
* DOCUMENTATION- Send all pertinent medical documentation to insurance companies and other payors for approval. Document final authorization in Cerner and scan all paperwork into Siemens scanning
* FRONT DESK - Answer phones at front desk and assist walk-in patients as needed. Provide after hours/weekend information desk coverage for the hospital. Re-identify patients for Blood Bank and Health Information Management Department. Organize folders for floor visits to patients. Admit surgical patients and direct admits that present to the Admitting office. Input all pre-admits for PALS and direct admissions as appropriate. Log all admissions in the Admitting logs.
* PATIENT CARE - Accept and issue patient's valuables from patients and the Emergency Department Staff. Perform floor visits to interview patients after a direct admit from the Emergency Department or the clinics
* CASH - Reconcile and complete cash reconciliation reports;
balance and post payments, contractual allowances, and denials
* REPORTS - Obtain police reports when appropriate for billing information for Patient Financial Services. Do the Census reports for PBX. Work Medicare secondary payor report as assigned
* RELATED WORK - Perform related duties and responsibilities as required
* SIGNATURE - Obtain proper signatures for Medicare Rights Consent for Treatment, financial forms for applying for assistance, and other forms as appropriate;
assure that patient rights are distributed
* INFORMATION - Interview patients and/or family at time of admission, pre-admission or discharge to obtain accurate demographic, and financial information;
update information on Hospitals computer system to ensure correct billing;
register patients for the Laboratory and clinics after hours;
provide billing information to Ambulance Services

Education:
Essential:
* High School or GED Equivalent

Experience:
Essential:
2 years directly related experience
Nonessential:
Bilingual English/Keres, Tewa, Tiwa, Towa, Zuni, or Navajo

Credentials:
Essential:
* Not Applicable/Not Required

Physical Conditions:
Sedentary Work: Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

Working conditions:
Essential:
* No or min hazard, physical risk, office environment
* May be required to travel to various work sites
* May be required or is required to rotate work shifts

Department: Behavioral and Mental Health