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Join Team Tidelands and help people live better lives through better health!

POSITION SUMMARY: The purpose of this position is to obtain prior authorizations or provide financial clearance for patients of Tidelands Health. This role is key to securing reimbursement and minimizing organizational write offs. The Pre-Services Representative must consistently demonstrate skilled communication and troubleshooting techniques as well as excellent customer service skills. This position will have the ability to anticipate and respond to a wide variety of issues/concerns, and the ability to execute tasks efficiently and effectively. The position requires the ability to independently plan, schedule and organize numerous tasks as this position directly impacts hospital and physician reimbursement.

The Pre-Services Representative II is responsible for accurate and complete insurance verification, financial clearance and prior authorization, and complete pre-registration of all scheduled moderately complex procedures, while utilizing excellent customer services standards.

DUTIES:

Confirms the need for an authorization and takes the appropriate actions to ensure the authorization is obtained.

Verifies the basic patient/service information is available - the minimum data set for scheduling a service. If not present, initiates appropriate activity to obtain the required data set, such as procedure codes.

Prioritizes the urgency of the authorization by anticipating the approximate time it may take obtain the authorization from the insurance company, the complexity of the procedure and the scheduled date of service; follows up with insurance company to accelerate responses and expedite urgent/emergent authorizations.

Evaluates or assists with the evaluation of cases when the insurance company has denied payment to determine next steps; this may include building a case for appeal.

Interacts with medical and professional staff to obtain appropriate clinical documentation for review; this may include referring stakeholders to a member of the clinical authorization team. Takes the appropriate actions when it appears that the authorization will be not be provided on a timely basis; to include escalation to the clinical authorization team.

Understands the critical delineations of patient status (outpatient, inpatient and observation) based on payor regulations and participates in the appropriate decision making with the clinical team members such as care management or with billing.

Advises and coordinates with providers regarding problematic (i.e. high risk) admissions or any episode of service requiring additional attention.

Performs various administrative support duites for department/work location. Opens, sorts and distributes all types of mail and correspondence as is necessary and assigned.

LEVEL OF RESPONSIBILITY:

The Pre-Services Representative I is responsible for accurate and complete insurance verification, financial clearance or prior authorizations, and complete pre-registration of all scheduled clinic visits and office-based/provider procedures, while utilizing excellent customer services standards.

EDUCATION REQUIRED:

High School Diploma or equivalent, required.

EXPERIENCE REQUIRED:

At least one (1) year of experience in Healthcare Revenue Cycle that includes prior authorization.

ADDITIONAL PREFERRED EXPERIENCE:

Knowledge of CPT and ICD coding preferred.

Knowledge of Medicare and third-party payer regulations and guidelines highly desired.

KNOWLEDGE/SKILLS/ABILITIES (KSAs):

Ability to interact successfully with the public. Ability to perform effectively despite sudden deadlines and changing priorities; maintaining personal composure in high stress situations.

Ability to demonstrate a high level of interpersonal skills required to interact with patients, patients’ families/visitors and clinical staff.

Ability to perform with a high degree of accuracy and with meticulous attention to detail. Demonstrate a strong ability to use initiative and judgment and to identify, analyze and solve problems.

PHYSICAL REQUIREMENTS: LIGHT PHYSCIAL AGILITY TEST RATING (PAT) 

While performing the duties of this job, the employee is frequently (activity or condition exists from 1/3 to 2/3 of the time) required to stand, sit, and walk; frequently to use hands, fingers; and frequently to talk or hear. The employee must exert up to 15 pounds of force occasionally (activity or condition exists up to 1/3 of the time), and/or up to 5 pounds of force frequently, and/or a negligible amount of force constantly to move objects.

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job and will be tested by post offer PAT.

Tidelands Health is an equal opportunity employer (EOE). Tidelands Health does not discriminate against employees or applicants for employment on the basis of race, color, creed, religion, age, national origin, disability, marital status, veteran status, gender, genetic information, familial status, or any other legally protected status.