Purpose: Responsible for the patient insurance verification process to ensure proper payment from insurers, provider assistance to reduce out-of-pocket expenses related to all services performed in a clinical setting including Prep/Sexual Health services, Assess and enroll patient in other assistance programs for which they qualify, Interpret and apply sliding fee scale and ensure that documentation related to the sliding fee scale is accurately and consistently captured in the electronic medical record. Enroll eligible patients into Ryan White Part C/FQHC programs at intake and alerts patients to recertify annually, Coordinate all referrals from Trillium providers, ensure patients/clients are scheduled for their services, and track open referrals for proper follow through of appointments. Inform and advises on policies and procedures related to uninsured patients. Ensure cross-departmental support and collaboration.
Key Job Responsibility Areas
- Patient Insurance Verification Process
- Ryan White Part C Enrollment and Recertification
- Coordinate Referrals
- Tracking Referrals
- Sliding Fee
- Policy and Procedures
- Cross-Departmental Support/Collaboration
- Miscellaneous
Detail of Key Job Responsibility Areas
1. Patient Insurance Verification Process
- Perform insurance verification checks at least three days prior to patient appointment in order to maintain compliance with Ryan White legislation and associated guidelines.
- Ensure “primary” and “secondary” valid insurance designations are accurately represented in electronic health record
- Contact patient when insurance checks result in invalid status and establish strategy for addressing gaps (referrals to services, possibly rescheduling patient until insurance matters have been resolved, etc.)
- Ensure patient demographics are maintained with updated information.
- Assess patient for eligibility for Medicaid, Medicare, and private insurance available through ACA marketplace and assist patients in applying for assistance.
- Assist patients in applying for insurance assistance during ACA open enrollment.
- Populate “know your coverage” scorecard and educate patient on information in scorecard.
2. Ryan White Part C Enrollment and Recertification
- Enroll patients into Ryan White Part C program at intake, conduct 6 month and annual recertification. At each recertification, determine the patient’s level of Ryan White Sliding Fee Scale and Cap on Charges and educate patients about these benefits.
- Assess patient for eligibility for Medicaid, Medicare, and private insurance available through ACA marketplace and assist patients in applying for assistance.
- Manage enrollment paperwork, primary insurance, proof of residency, and proof of income.
- Monitor patient progress toward Ryan White Cap on Charges and adjust a patient’s cap in coordination with Billing and document it consistently in the electronic medical record as needed.
- Educate patient on Ryan White program “benefits” and services.
3. Coordinate referrals
- Assign the patient to the appropriate specialty provider or facility based on the patient’s current medical needs as defined by the primary care provider
- Provide all the required medical history information regarding the patient to the specialty provider or facility.
- Coordinate with insurance carriers and specialty practices to obtain prior authorizations, pre certifications and referrals on applicable plans which include HMO, PPO and POS health plans and documents all benefit information into the patients’ electronic medical record.
- Enter all the referral information into the electronic medical record system.
- Contact patient, specialty provider or facility to reschedule missed appointments for patients as applicable.
4. Referral Tracking
- Keep track of patient/client referrals in the system and follow up with clients who have missed referral appointments.
5. Sliding Fee Scale
- Interpret and apply sliding fee scale for FQHC Sliding Fee Scale and the Ryan White Sliding Fee Scale; ensure documentation related to sliding fee scale is accurately and consistently captured in electronic medical record.
- Responsible for educating patients and prospective patients on sliding fee scales.
6. Policies and Procedures
- Follow all established policies & processes related to uninsured patients.
7. Cross-Departmental Support/Collaboration
- Communicate directly with patients who submit billing & reimbursement questions through the patient portal.
- Collaborate with Front Office Teams to coordinate enrollment and eligibility follow-up as needed.
8. Miscellaneous
- Requires the ability and commitment to respect and support inclusiveness and diversity including but not limited to individuals of different backgrounds, cultures, races, ages, sexual orientations, gender identities or expressions, experiences, opinions, etc.
- Requires individual demonstration of commitment to the One Trillium behaviors and business impacts and modeling them in the organization.
- Responsible for maintaining confidentiality of all patient, client, employee, protected and proprietary information.
- Employees are accountable for meeting the performance standards of their departments and must participate as requested in compliance audits, process improvement and quality improvement plans.
- Other duties as assigned.
Qualifications
Bachelor’s degree preferred. At least three years’ of experience in human services/medically based setting required. Preferred to hold a valid NYS certificate as Insurance Assister. Knowledge of sliding fee scale. Knowledge of insurance and experience with prior authorizations required.
Competencies
- Effective performing multiple tasks during workday.
- Proficiency in MS Office and computer/automated systems for data purposes.
- Proficiency with electronic medical records systems.
- Excellent organization, communication and interpersonal skills a must with the ability to communicate effectively verbally and in writing; and utilize good listening skills.
- Ability to work effectively in a collaborative, team-based work environment, including the ability to positively receive and give constructive feedback.
- Ability to function autonomously as a worker and as a team member on a multidisciplinary team
Physical Requirements
While performing the duties of this job the employee is required to stand, sit, walk, use hands to finger, handle, or feel; reach with hands and arms, talk and hear. Occasionally the employee must stoop, bend and lift or move up to 25 lbs. Specific vision abilities required include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus.
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.
