Major Responsibilities:

• Evaluates HME referral and service order requests to ensure smooth and timely transition for patient from hospital to home while ensuring the patient is supported safely and insurance benefits are optimized. Advocates for patient serving as a liaison to explain prescription order, hospital transition and home start of care process, and insurance benefits. Access service requests in relation to organization acceptance criteria and evaluates medical documentation to ensure payer coverage criteria are satisfied. Verifies patient insurance benefits and eligibility and contacts insurance plan to obtain service prior authorization as needs and determines patient co-insurance. Provides direction to physicians on how to resolve documentation or medical management gaps when documentation does not support medical necessity or payer coverage criteria. Identifies risk issues and collaborates with patient, physician, hospital staff and other care providers to ensures resolution and patient safety. Coordinates timely provision of service with distribution operations and the patient.
• Provides quality customer service for all customers, including patients, physicians, referral sources, and coworkers within Advocate Aurora Healthcare and external customers. This requires the team member to respond courteously and professionally to client requests and concern and follows through to appropriate resolution. Be diligent in regards to making sure that there is current, correct authorizations for all managed care clients in order to assure that the client's needs are met and to assist other Advocate Aurora departments in being more efficient. Adheres to the processes that have been established to insure quality customer service to all customers, such as Electronic referrals, HME coding, Pickups and faxing. Also, having flexibility to take on additional responsibilities as to assist in resolution of customer concerns as well as other business needs.
• Be proficient in the use of the computerized resources and data entry programs involving proper processing and qualifying of patients with HME business line needs. Monitor and work all necessary insurance verification reports for assigned products lines and assigned payors. Runs, collects and tabulates data and submits to management selected and assigned reports.
• Identify, investigate and verify sources of reimbursement and make recommendations based on the information obtained. The team member will obtain and document payor eligibility information for each new referral, addition to service and re-admission and determine if payor's coverage requirements are met for services or equipment. They will also assess potential third-party liability cases to determine who is the primary payor and relay the appropriate billing requirements to the patients accounts staff and operations. Other requirements include checking with referral sources for any intermittent services that might be need by the patient and suggest companion items for the equipment ordered to better service our patient.
• Provide pricing information to explain the financial responsibility to patients. This requires the team member to assess the patients ability to pay and negotiate payment plans and determine their financial risk at the time of referral. If necessary also, recommend appropriate action and notify patient and/or family of the expected financial responsibility at the start of care.
• Participates in performance improvement and patient satisfaction initiatives. Serve as a member of department division or system performance or process improvement group as appropriate. Work with management to implement change and identify opportunities for improvement.
• Continuously updates knowledge of Medicare, Medicaid, HMO and managed care of the complex and ever evolving coverage requirements and guidelines.

Licensure, Registration, and/or Certification Required:

• None Required.

Education Required:

• High School Graduate.

Experience Required:

• Typically requires 5 years of experience in medical entry, claims processing, HME business line, home care, insurance verification, home care customer service or other healthcare related position. Knowledge of HME/RT equipment. Understanding of third party payors, including Medicare, Medicaid and private insurance companies.

Knowledge, Skills & Abilities Required:

• Regularly interfaces with representatives of third party payers
• Wide range of contacts with hospitals, long term care facilities, rehab and therapy facilities, physician's offices, case managers, utilization review managers, patients and their families. Communication is both verbal and written.
• Determine acceptance of patient with low financial risk, high risk cases and appropriately search out the resources.
• Prioritization of insurance verification and prior authorization to ensure department goals and objectives are obtained.
• Monitor all managed care patients' supply orders and re-orders to insure that adequate and current authorization is in the data base so as to enhance quick reimbursement.
• Troubleshoot equipment problems appropriately seek out further assistance if needed.
• Handle confidential information on every client.
• Function under tight time constraints to verify insurance benefits before delivery of equipment, of data entry of referral information necessary for delivery ticket with proper
• qualifying diagnoses for each piece of ordered equipment.
• Heavy volume of daily incoming and outgoing phone calls and documents must be processed timely and accurately. Very fast paced. Strong data entry and phone skills.

Physical Requirements and Working Conditions:

• Exposed to an office environment.
• Must be able to sit, stand and walk for long periods of time. Must have the physical agility to move about in confined spaces, including bending, kneeling, squatting and occasionally reaching one or both arms over head.
• Must be capable of typing, writing and data entry for prolonged periods of time.
• Will occasionally lift 10 lbs.
• Operates all equipment necessary to perform the job.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.