Job ID: BH350395
Category: Administrative Assistant
Job Title: Admissions Counselor
Job Location: Somerville, MA
Hours: Monday – Friday, 8:00 AM – 4:30 PM or 8:30 AM – 5:00 PM
Co. Size: 26,000+ employees
- 2+ years of experience in a hospital setting or a related type of medical institution or medical payer organization
- Bachelor’s Degree
- Insurance or Managed Care Authorization knowledge
- Medical Terminology and/or coding knowledge
The Admissions Counselor functions as a prior authorization and insurance verification expert and is responsible for the in-depth review of all admissions and procedures. The Admission Counselor is responsible for ensuring the timely notification to all Payers and obtains patient prior authorization/pre-certification for elective DSU/PPR/Inpatient/Surgical admissions, Endo/Pain/Cardiology/Infusion Outpatient procedures, and all emergent authorizations for EDIP and EDOBS admissions, assessing and determining if auth is required and what additional follow up is needed to ensure payment to the hospital. He/she must also verify and/or collect required data, assuring its accuracy and integrity, including verification of insurance eligibility and any possible discrepancies which could impact the authorization requirements. Must document all notes and relevant data for completeness of authorizations. Reviews scheduled visits to determine financial requirements. Obtains appropriate preadmission approvals and precertification’s, confirming that third party requirements are met, prior to admission or visit. Identifies cases which might place the institution at financial risk and recommends referral to Patient Financial Services, when appropriate. Works closely with Practice staff and Clinicians regarding potential delays or deferrals of non-emergent cases until financial/authorization issues can be resolved. Maintains account from time of booking, until the final authorization is confirmed with the Payer for all days and all services rendered. Is responsible for ensuring data quality, in order to expedite billing and reimbursement process and minimize financial risk to the institution.
PRINCIPAL DUTIES AND RESPONSIBILITIES: Indicate key areas of responsibility, major job duties, special projects, and key objectives for this position. These items should be evaluated throughout the year and included in the written annual evaluation.
• Working from Ontrac worklist, identifies and prioritizes cases based on DOS and Payer High Risk level. Verifies and/or collects demographic and financial information on all scheduled and emergent admissions and visits in Epic. Enters/edits data on-line
• Enters/edits data in Epic and in Ontrac, ensuring accuracy and integrity, looking for discrepancies in Payer details, e.g., replacement plans, plan mismatches, additional payers, incorrect subscriber, etc., in order to avoid denials in authorizations for said discrepancies Must clearly document in Epic and Ontrac notes and status of case in accordance with QA requirements. Constantly working in two systems, Ontrac and Epic, as well as Payer websites.
• Contacts insurance companies, managed care plans, outside agencies, and intermediaries to verify insurance coverage and benefits. Determines if any pre-admission/pre-visit requirements exist, e.g., predetermination of medical necessity, need for out of network plan auth required in addition to the service/procedural auth, etc.
• Compiles and submits clinical information from Epic required to obtain preadmission approvals and precertification. Must review all pertinent clinical notes and test/radiology results to include in the submission. Works with doctors’ offices when notes are lacking such that an authorization may be denied and lead to a P2P. Communicates deficiency to doctors office which leads to improved or additional notes uploaded to Epic so auth submission is as complete as possible, averting potential P2P.
• Monitors pending cases to ensure that approvals are obtained prior to admission or visit. Informs doctor’s office of any additional clinical requested, including notes that are lacking tried and true therapies/refrainment’s, e.g., Orthopedic or Neuro Spine cases
• 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 the hospital regarding collection of liability.
• Reviews and follows-up on all emergency and unscreened admissions as soon as possible, within 24 business hours of admission at the latest, to identify and minimize financial risk to the institution.
• Follows all cases throughout the duration of the admission, transferring to UR Department every few days in Ontrac to send concurrent review clinicals. Must connect with Payer continually throughout the admission for updated authorization days, alerting UR to any medical necessity denials so they can conduct in-house P2P.
• Reviews RTE throughout admission for any Payer changes or discrepancies and follow up for new prior authorization when Payer changes mid-admission.
• Reviews cases daily for patient type changes in order to modify or request authorization updates.
• Reviews Ontrac list daily for exceptions which include some of the above, but in addition: expected date changes in surgery, primary and secondary payer changes, high risk high dollar accounts, and other important notifications.
• Scans authorization related information into Epic Media manager and documents notes in accordance with QA Metrics. Works closely with 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.
• Escalates cases to Team Lead, Manager and Director, as necessary for timely resolution.
• 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.
• Maintains effective working relationships and communicates regularly with Social Service, Care Coordination, Payers, Doctors and their offices, Central Billing Office, Office of General Counsel,
and other departments to update and exchange pertinent account information.
• 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 rules
• Performs special projects, covers other services, and other tasks when necessary.
QUALIFICATIONS: (MUST be realistic, neither overstated nor understated, and related to the essential functions of the job.)
• Bachelor’s degree or equivalent preferred; high school diploma required.
• Proven experience in like setting is acceptable in lieu of educational requirements.
• 2+ years’ experience in hospital setting such as Patient Access, Doctor’s Office, Inpatient Unit, Patient Accounts Billing, or at a related type medical institution or medical payer, e.g., BCBS, Tufts, etc…
• Knowledge of insurances and/or managed care authorization requirements a plus
• Knowledge of medical terminology and/or coding is helpful
• Familiarity with a hospital legacy system, Microsoft Office, and SharePoint preferred
• Bilingual is helpful
SKILLS/ ABILITIES/ COMPETENCIES REQUIRED: (MUST be realistic, neither overstated nor understated, and related to the essential functions of the job.)
• Demonstrated excellent customer service abilities
• Proficiency in oral and written communication
• Adeptness in assessing and solving problems, excellent organizational skills, and able to multi-task and prioritize
• Knowledge of revenue cycle particularly with regard to insurance reimbursement and managed care authorization and referral requirements
• Ability to effectively interact with various levels of the organization
• Ability to work independently, with minimal supervision
• The technical knowledge of specific legal and regulatory requirements and an understanding of complex third party and medical assistance policies and procedures.
• Knowledge of the hospital information system with emphasis on registration and insurance verification, and accounts receivables programs.
• Requires good judgment, tact, sensitivity, and the ability to function in a fast-paced environment.
• Ability to maintain confidentiality regarding the patients, their medical histories, demographic and fiscal
• Able to identify when something needs to be escalated to Senior Management, from a case level to an identified thematic level.
The Planet Group of Companies is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.