Insurance Clearance Rep Sr

Advocate Health Care; Oak Brook (IL); On-site; USD 25,000 - 39,000; Full time

Job summary

Advocate Health Care in Illinois seeks qualified staff to manage payor requirements, authorize inpatient/outpatient services, and guide patients through uninsured or out-of-network scenarios. The role also handles pre-registration, data entry, and patient education on required documents.

Candidates should have a High School diploma and at least 2 years in health care, insurance, call center, or customer service. Strong problem solving and communication skills are essential.

Qualifications

• Ability to problem solve in a high profile and high stress area.
• Ability to prioritize and organize workload.
• Mathematical aptitude, effective communication, and critical thinking skills.
• Excellent verbal and written communication skills.
• General computer knowledge.

Responsibilities

• Acquires and maintains current knowledge of payor requirements for authorizations and hospital billing.
• Performs insurance authorization of inpatient and outpatient services.
• Consults with patients and departments for uninsured/out-of-network statuses and provides next steps.
• Ensures completion of policies for patient identification and notification in HMO coverage cases.
• Pre-registers and registers patients and enters accurate demographic and insurance information into ADT system.
• Generates and processes documents for patient registration and educates patients on required signatures.

Skills

Problem solving

Prioritization

Math & critical thinking

Verbal & written communication

Computer literacy

Education

High School Graduate

Job description

• Acquires and maintains current knowledge of all payor requirements as it relates to patient/hospital responsibility for authorizations and hospital billing, including all Federal and State regulations. Performs all insurance authorization of inpatient and outpatient services, by accurately collecting and analyzing clinical data in support of payor guidelines and submits accordingly. Uses resources to determine appropriate procedure codes for authorization to ensure appropriate reimbursement.
• Consults with patient and appropriate departments for uninsured status, uncovered services, out of network status and situations where the only insurance is Third Party Liability or Workers Compensation and provides next steps. Initiates communication to the patient when authorization is not obtained and explains the potential financial responsibility.
• Maintains knowledge of all stand‑alone computer software programs to verify eligibility and authorization.
• Ensures completion of all established policies and procedures for identification and notification of the Primary Care Physician in the case of HMO coverage. Identifies at risk balances related to Medicaid eligibility rules and communicates to Financial Counseling, Utilization Management, and physicians. Completes cancelations and accurately reschedules patient according to department procedures.
• Manages incoming and outgoing calls to complete pre‑registration with patients. Pre‑registers and registers patients using established procedures for computer entry for all ancillary and nursing units, keeping current with the specialised needs, and preparing necessary documents/records when necessary. Ensures accurate entry of patient demographic and insurance information in the ADT system with special attention to carrier code assignment, complete benefit, eligibility record and authorization data.
• Generates and processes all required documents for completion of registration, providing detailed education to the patient on the documents and forms requiring patient signature.
• Participates in department staff meetings and keeps abreast of continuing education to ensure effective communication and to maintain skill competency. Seeks out education opportunities to increase knowledge in department procedures as it relates specifically to scheduling needs for that area.
• Attends all mandatory in‑services 100% and completes all mandatory safety in‑services and skill competencies as required. Actively participates in group projects to problem solve department issues.
• Operational knowledge of the various Advocate Aurora Health departments so that patient, visitor, and fellow employee questions are answered or referred in an appropriate manner. Maintains confidentiality of patients records by following HIPAA and all compliance policies and guidelines.

Major Responsibilities

• Acquires and maintains current knowledge of all payor requirements as it relates to patient/hospital responsibility for authorizations and hospital billing, including all Federal and State regulations. Performs all insurance authorization of inpatient and outpatient services, by accurately collecting and analyzing clinical data in support of payor guidelines and submits accordingly. Uses resources to determine appropriate procedure codes for authorization to ensure appropriate reimbursement.
• Consults with patient and appropriate departments for uninsured status, uncovered services, out of network status and situations where the only insurance is Third Party Liability or Workers Compensation and provides next steps. Initiates communication to the patient when authorization is not obtained and explains the potential financial responsibility.
• Maintains knowledge of all stand‑alone computer software programs to verify eligibility and authorization.
• Ensures completion of all established policies and procedures for identification and notification of the Primary Care Physician in the case of HMO coverage. Identifies at risk balances related to Medicaid eligibility rules and communicates to Financial Counseling, Utilization Management, and physicians. Completes cancelations and accurately reschedules patient according to department procedures.
• Manages incoming and outgoing calls to complete pre‑registration with patients. Pre‑registers and registers patients using established procedures for computer entry for all ancillary and nursing units, keeping current with the specialised needs, and preparing necessary documents/records when necessary. Ensures accurate entry of patient demographic and insurance information in the ADT system with special attention to carrier code assignment, complete benefit, eligibility record and authorization data.
• Generates and processes all required documents for completion of registration, providing detailed education to the patient on the documents and forms requiring patient signature.
• Participates in department staff meetings and keeps abreast of continuing education to ensure effective communication and to maintain skill competency. Seeks out education opportunities to increase knowledge in department procedures as it relates specifically to scheduling needs for that area.
• Attends all mandatory in‑services 100% and completes all mandatory safety in‑services and skill competencies as required. Actively participates in group projects to problem solve department issues.
• Operational knowledge of the various Advocate Aurora Health departments so that patient, visitor, and fellow employee questions are answered or referred in an appropriate manner. Maintains confidentiality of patients records by following HIPAA and all compliance policies and guidelines.

Licensure, Registration, And/or Certification Required

• None Required.

Education Required

• High School Graduate.

Experience Required

• Typically requires 2 years of experience in health care, insurance industry, call center, or customer service setting.

Knowledge, Skills & Abilities Required

• Ability to problem solve in a high profile and high stress area.
• Ability to prioritize and organize workload.
• Mathematical aptitude, effective communication, and critical thinking skills.
• Understanding of basic human anatomy and medical terminology.
• Excellent verbal and written communication skills.
• General computer knowledge.

Physical Requirements And Working Conditions

• Must be able to sit most of the workday.
• May include intermittent light travel.
• 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.