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Senior Practice Assistant, Pain Prior Auth

2 months ago

Chestnut Hill, United States Brigham & Women's Hospital(BWH) Full time

Brigham and Women's Hospital is committed to putting every Patient First. Every employee plays a role in providing a positive impact on patients and the care they receive at Brigham and Women's Hospital. Your work will be distinguished by the delivery of high-quality and safe patient care, respect and dignity in all interactions with patients, families and colleagues and by customer service excellence.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Perform duties under moderate supervision with intermediate to advanced proficiency in administrative skills.

• Interacts directly with EPIC Auth/Cert, Registration and Referral Shell, entering data accurately to coordinate all elements required for payment of services rendered, which includes, but is not limited to, appropriate CPT Procedure and Diagnosis codes, rendering Physician(s), level of care, and facility, i.e., across entities (BWH, BWFH, FXB, etc.). There are differences across the entities that need to be realized. At times will need to coordinate DFCI and/or Boston Children Hospital care that fall under special agreement with these entities. Uses independent judgement to make knowledgeable decisions in organizing with physician and office to respond to Medical Insurance inquiries and resolving conflicts concerning approval for surgical procedures in the OR.

• Interacts directly in EPIC Clinical System to extract necessary supporting clinical data to submit to Medical Insurance to secure authorization, e.g., clinical office notes, radiology reports, lab test and results, PT/OT notes, imaging results and photos. Each type of surgery, as well as each insurance company has different needs for information required to authorize the surgery, and review and understanding of all is needed to get an approval for services.

• Contacts insurance companies, managed care plans, outside agencies, and intermediaries to verify insurance coverage and benefits.

• Ability to identify incomplete clinical documentation that is needed to obtain approval for services. Interacts directly with physicians/clinicians/physicians' office staff via EPIC, phone calls and Outlook to identify what is missing and to collect further complete and appropriate patient data and clinical information necessary to submit to Medical Insurance to review for authorization of services scheduled.

• Compiles, uploads, and submits all the above clinical information from Epic required to obtain preadmission approvals and precertification via the Medical Insurance Payer Portals.

• Monitors pending cases to ensure that approvals are obtained prior to visit. Informs doctor of any additional clinical requested, including notes that are lacking tried and true therapies/refrainment, e.g., Physical therapy.

• Advises uninsured and underinsured patients regarding available programs. Makes appropriate referrals to Patient Financial Services Department in a timely manner so that coverage may be secured ASAP and the accompanying authorization, if any, is submitted as soon as Payer source is identified.

• Advises and refers to Patient Financial Services when it appears a patient liability estimate is in order. Works closely with PFS, Practice staff and the patient or his/her family to aid in an understanding of liability and informs of the expectations of Brigham Health regarding collection of liability.

• Scans authorization related information into Epic Media Manager and documents notes in accordance with QA Metrics. Works closely with Authorization Denials Team to avert write offs by researching cases and providing back-up documentation for possible prior auth appeals.

• Stays current with Payer changes in authorization requirements and restrictions, e.g., additional CPT procedure codes now requiring authorizations, or additional tried therapies, etc.

• Maintains a daily workflow of Ontrac work lists and keeps Epic auth/cert fields and notes updated prior to, throughout, and post service until case is in final secured status and authorization is complete for billing purposes.

• Maintains patient confidentiality and privacy by accessing patient information only to the extent necessary to fulfill assigned duties. All patient information must be kept private, confidential, and secure. All lists, reports, files, and documents must always be properly secured and stored. Interviews and examinations should be conducted in such a manner as to afford the patient reasonable audio and visual privacy.

• Adheres to Customer Service Standards (Service Excellence) by demonstrating professionalism, alertness, helpfulness, and receptiveness to all patients, visitors, and other staff members.

• Employs discretion when leaving answering machine messages, or sending faxes adhering to HIPAA rule

• Performs special projects, covers other services, and other tasks when necessary.

• Utilize knowledge of HMO's, managed care and other third-party insurers, and troubleshoots insurance issues as appropriate.

• Checks schedules for referrals and contacts Patient Service Center for missing referrals.

• Works closely with physicians and case managers to provide timely documentation for workers compensation patients including responding to denials and the appeals process.

• Obtains all referrals/prior authorizations for procedures for Mass Health,NHP,HP,B/C,MR, Tufts and all other insurers. Works closely with clinic staff and lead biller, specifically for denials.

• Coordinates peer to peer reviews with the insurer and provider when a request for a procedure is denied.

• Educates patients being seen in PMC regarding PMC referral/authorization requirements. Serves as patients' primary contact within the Pain Management Center for understanding insurance requirements, worker's comp and prior approval processes. Makes calls to patients to inform them of approval or denial for procedures.

• Works with the providers to ensure that patients' medical documentation complies with insurance requirements.

• Responsible for educating staff about changes in managed care and other insurance requirements.

• Assists Lead Revenue Cycle/ Managed care coordinator with denials work-queue

• All other duties as assigned.

SKILLS/ ABILITIES/ COMPETENCIES REQUIRED:

• Excellent customer service skills.

• Ability to prioritize work load when processing referrals and authorization requests per guidelines and within specified turn around timeframes.

• Ability to process high volume of requests with a 95% or greater accuracy rate.

• Effective collaborative skills.

• Strong oral and written communication skills.

• A strong working knowledge of Microsoft Office products.

Qualifications

Level of education required:

  • Minimum of a high school diploma or GED.
Work experience required:
  • Minimum one year applicable work experience required.
  • Some additional training in office systems or other post high school education preferred.


EEO Statement

BWH is an Affirmative Action Employer. By embracing diverse skills, perspectives, and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.