Coord Insurance Spec (BMG) in South Bend, Indiana at Beacon Health System

Reports to the Director/Manager of Oncology Service line. Coordinates the daily operational activities of Oncology Insurance Specialist associates (i.e., assigns work, facilitates department meetings and is responsible for associate scheduling, annual reviews and disciplinary actions, etc.).

MISSION, VALUES and SERVICE GOALS

• MISSION: We deliver outstanding care, inspire health, and connect with heart.
• VALUES: Trust. Respect. Integrity. Compassion.
• SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.

Coordination of Denials and Authorization/Pre-Certification functions by:

• Coordinates the team to ensure that pre-certification authorizations are completed accurately for all outpatient and inpatient chemotherapy/infusion therapy, outpatient diagnostic procedures, outpatient and inpatient planned surgeries, specialty lab testing and therapeutic radiation oncology treatments s ordered by providers.
• Responsible for follow-up and resolution on insurance/authorization related denial issues for oncology service line.
• Responsible for reporting to management on trends/denials/concerns and working collaboratively to resolve.
• Responsible for ongoing education of coding, billing, and payer updates across Insurance Specialist team.
• Supervises team for appropriate coverage of services across all areas to maintain quality, efficient work without interruption to patient care.
• Distributing work assignments for team members to ensure that all verification of benefits, medical necessity checks, authorizations/pre-authorizations have been finalized.
• Auditing authorizations for accuracy.
• Investigating daily 835 denials for continuous process improvement.
• Ensuring that pre-certification authorizations are complete for all scheduled outpatient diagnostic, outpatient and planned inpatient surgeries, and specialty lab testing.
• Ensuring that pre-certification authorizations are completed on all planned chemo admissions.
• Following up with oncology schedulers and physicians to address errors in pre-certifications that have been submitted and requesting rescheduling of the procedure.
• Notifying patients of non-coverage or limited coverage.
• Working closely with social work and financial counselors on self-pay or under insured patients.
• Explaining about the possible need to pre-certify with the patient's insurance carrier in order to ensure maximum coverage to the limits of the insured's insurance policy.
• Verifying and documenting insurance coverage via online eligibility systems, internet resources or via telephone.
• Validating medical necessity via the MCA Compliance Checker where applicable.
• Ability to efficiently access insurance payer portals for best practice of obtaining authorizations.
• Investigating and responding to insurance-related concerns from patients and/or oncology office staff.
• Actively participates and helps to coordinate denial meetings and helps to follow up on ongoing denials until they are resolved.
• Delivers accurate documentation to Insurance Companies.
• Works closely with BMG Oncology physicians and clinical staff to obtain prior authorizations for treatments, procedures, medications, and surgeries.
• Advises office staff when requested procedure(s) have been denied or an insurance company is requesting a peer to peer. Provides all necessary information and documentation in order this to be addressed.
• Communicates effectively with staff regarding authorization-specific details (ie; doses, units, visits).

Coordinates both the Denials and Authorization/Pre-Certification/documentation (PA) processes for patients by:

• Running insurance eligibility, make needed phone calls to insurance companies, fax authorization requests.
• Works closely with Patient Accounts to properly follow up on insurance company denials and appeals.
• Obtaining pre-certification information from the insurance company's pre-certification unit (i.e., whether pre-certification is required, if the ordering physician has completed it, etc.).
• Securing authorization on all patients for ancillary, surgical, and out-patient testing/procedures/admissions.
• When the authorization is not completed prior to the ordered procedure, assists with ensuring that the procedure is cancelled or rescheduled.
• Runs & ensures medical necessity is complete with proper CPT and ICD-10 codes as physician order specifies.
• Identifying out of network insurance plans and follow the out of network policy.
• Keeping accurate worklists and documentation.

Coordinates other patient services and performs clerical duties by:

• Reviews all insurance coding changes regarding updates to HCPCS and CPT codes.
• Verifies treatment meets medical necessity per diagnosis given by providers.
• Calculating co-payments and coinsurance for services rendered (either verbally or in writing) per the insurance companies' request.
• Processing denials and authorizations in an efficient manner.
• Answering the telephone and communicating information in an appropriate manner according to approved Beacon standards and departmental policies and procedures.

Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by:

• Communicates and educates providers and staff on any documentation issues in a timely manner in order to correct errors or omissions in the oncology medical record.
• Responsible for delivering feedback to other insurance specialists in the department.
• Schedules, organizes and facilitates department meetings and is accountable for all information shared.
• Monitoring and holding staff accountable for quality of work.
• Training and onboarding new insurance specialists within the oncology department and helps provide updates to new insurance guidelines.
• Providing world class service at all times.
• Assisting the department to meet or exceed its quality assurance goals.
• Works closely with the physician office staff to ensure that pre-cert/pre-authorization numbers are obtained & entered in the registration system.
• Acting as a representative of Beacon and striving to make a good first impression.
• Striving to accurately process an optimal number of authorizations during one's shift.
• Communicating with the Manager or Director regarding any concerns or problems.
• Responding to questions and issues and communicating resolutions to management or other areas in a timely manner as applicable.
• Maintaining records, reports and files as required by departmental policies and procedures.
• Completing other job-related duties as assigned.

ORGANIZATIONAL RESPONSIBILITIES

Associate complies with the following organizational requirements:

• Attends and participates in department meetings and is accountable for all information shared.
• Completes mandatory education, annual competencies and department specific education within established timeframes.
• Completes annual employee health requirements within established timeframes.
• Maintains license/certification, registration in good standing throughout fiscal year.
• Direct patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
• Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
• Adheres to regulatory agency requirements, survey process and compliance.
• Complies with established organization and department policies.
• Available to work overtime in addition to working additional or other shifts and schedules when required.

Commitment to Beacon's six-point Operating System, referred to as The Beacon Way:

• Leverage innovation everywhere.
• Cultivate human talent.
• Embrace performance improvement.
• Build greatness through accountability.
• Use information to improve and advance.
• Communicate clearly and continuously.

Education and Experience

• Extensive knowledge of the latest alphanumeric codes used in medical billing, so post-secondary training is required. The knowledge, skills and abilities as indicated below are normally acquired through the successful completion of an associate�s degree majoring in medical billing, medical coding, health informatics, health information technology, or a related healthcare field certification. A minimum of 3 years of oncology experience in a hospital or physician practice business office and/or insurance prior authorization and verification of benefits is required. Excellent leadership, time management, organizational skills, research/analytical skills, negotiation, communication (written and verbal), and interpersonal skills required. Must have computer experience and be able to keep accurate insurance records.

Knowledge & Skills

• Requires basic office and keyboarding skills (with the ability to type a minimum of 40 wpm) and the ability to use designated reference materials and office equipment (i.e., computer, printer, fax machine, calculator, etc.).
• Knowledge of medical terminology in regards to procedure and diagnosis codes, insurance policies, coverage of networks, legislation, equipment and professional disciplines.
• Demonstrates communication and interpersonal skills necessary to effectively interact with patients and guarantors.
• Knowledge in Medicare and Medicaid guidelines.
• Demonstrates the interpersonal skills necessary to interact effectively with patients from various backgrounds in a professional, enthusiastic, courteous, friendly, caring and sincere manner. Also demonstrates the ability to maintain effective working relationships with other departments, physicians and their office staff.
• Demonstrates the verbal communication skills needed to communicate in a clear and effective manner when communicating with insurance companies, other departments, and physician offices.
• Detail-oriented with good organizational skills will help health insurance specialists file all essential insurance paperwork correctly.
• Good listening skills are required. Sensitivity to individuals who do not speak English as their first language is expected.
• Requires the ability to strictly follow Beacon's policy on confidentiality. Also requires the ability to be aware of the need to lower one's voice in certain situations.
• Requires ability to utilize good judgment and maintain one's composure in stressful situations.
• Requires the basic math skills needed to calculate patient's insurance benefits such as deductible, coinsurance, and out of pocket, as well dosing for units of authorization when it comes to medications.

Working Conditions

• Ability to adapt to change and close working conditions.
• Potential to work remote or on-site if needed.
• May need to travel to other Beacon locations.
• Assigned hours within your shift, starting time, or days of work are subject to change based on departmental and/or organizational needs.