Patient Precertification Associate

About the Job

General Summary of Position

The individual in this position provides assistance to patients in the department. The individual is responsible for coordinating all the functions and activities related to patient pre-certification/authorization including but not limited to: accurate and complete patient registration in the approved organization electronic scheduling and billing systems and on-site insurance verification. These functions are performed in accordance with all applicable laws and regulations and Georgetown University Hospital's (GUH) philosophy policies procedures and standards.

Primary Duties and Responsibilities

* Referrals/Authorizations Verifies eligibility and conformance to Georgetown Physicians Group (GPG) GUH and departmental managed care requirements and contracts. References the Med Star Managed Care Matrix and on-line Handbook as necessary. Obtains insurance referrals and pre-authorizations. Submits all referral information to necessary providers as appropriate.

Assists with pre-authorizations of hospital admissions procedures medications and medical equipment.

* Maintains ongoing communication with insurance companies to determine eligibility of benefits deductible status and to obtain precertification for office-based and other procedures. Educates and informs patients and families regarding verification status and issues related to deductibles co-payments and balances. Responds to hospital staff and/or patient inquiries regarding referrals authorizations and scheduling in an efficient manner

* Registration Will search the Enterprise Access Directory (EAD) to establish if the patient is new or existing. Follows guidelines to avoid duplicate medical record assignment.

Obtains and/or verifies complete demographic and insurance information from patient. Accurately enters complete demographics insurance information and Financial Status Classification (FSC) / Hospital Patient Accounting Plan Code assignment into the approved organization electronic scheduling and billing systems.

* re-certification/Authorization & Billing Is responsible for resolving all outstanding Alerts on pending appointments within 48 hours of the scheduled appointment to minimally include:

Missing Referral Missing Pre-certification/Authorization Self Pay Accounts Eligibility Verification Missing Demographic/Insurance Information

* Med Star and/or Georgetown University Hospital specific requirements

Enters all relevant data linking to the appropriate appointment/visit and ensures all required data elements are captured.

Ensures all relevant data is entered into the Open Referrals Module links data to the appropriate appointment / visit and enters the required data elements to ensure that accurate billing information is submitted to the . appropriate insurance carrier.

Obtains any missing pre-certification or authorization numbers and enters into the appropriate field in the Appointment Data Form (ADF).

* Establishes if the appointment needs to be rescheduled due to missing Referral or Authorization number. Works with departmental supervisor and/or clinician to determine medical necessity and if the appointment can be rescheduled. If appropriate notifies the patient that the appointment needs to be rescheduled due to missing Referral/Pre-certification/Authorization

* Reviews patient accounts with self-pay status. Confirms that patients understand the need to make payment on outstanding balances. Reviews rejected accounts to provide updated information to Physicians' Unified Billing Service (PUBS) and relays appropriate information regarding denied claims to patients when necessary.

Where appropriate and within GUH guidelines ensures collection of pre-payments/deposits due from the patient prior to service for elective cases and prior to the procedure for add-on cases.

* Reviews encounter forms to ensure appropriate data is being collected according to GUH guidelines. Performs coding and error resolution.

Where appropriate reconciles operative log report to ensure all procedure fees have been submitted to PUBS. Reconciles Admissions Discharges and Transfers (ADT) reports to ensure all inpatient visits have been submitted to PUBS. Completes daily deposit by completing Official Receipts and Journal Vouchers for processing payments. Maintains deposit logs and records. Researches and resolves any deposit discrepancies.

At the end of each day or session batches encounter forms prepares Batch Entry Form and Batch Control Log to be sent to PUBS.

* Compiles and runs the Missing Charge Report each month and assists Administrator with reconciliation of missing charges. Performs quality audits as requested.

Serves as liaison to PUBS and Patient Financial Clearance Unit (PFCU). Reviews rejection reports ensures that corrective action is taken on all denied charges and that all charge sheets are resubmitted to PUBS for processing. Provides cross-coverage to Front Desk Check-in / Check-out position. Assists with payment and billing…