Insurance Clearance Representative

Advocate Health Care; Oak Brook (IL); On-site; USD 43,000 - 62,000; Full time

Job summary

Advocate Aurora Health seeks a Credentialing/Registration professional to handle patient registration, pre-registration, and insurance authorization. This role ensures accurate demographic and insurance entry, communicates financial responsibilities, and supports billing processes across inpatient and outpatient services.

Responsibilities include verifying eligibility, educating patients on required forms, and maintaining compliance with HIPAA and hospital policies.

Qualifications

• Knowledge of patient registration and pre-registration processes.
• Familiarity with HIPAA and confidentiality of patient data.
• Attention to detail in data entry and eligibility data.

Responsibilities

• Acquires and maintains knowledge of payor requirements for authorizations and billing.
• Performs insurance authorization for inpatient and outpatient services to support reimbursements.
• Communicates uninsured status and potential financial responsibility to patients and departments.
• Verifies eligibility using software programs and confirms authorization data.
• Identifies Medicaid eligibility risks and communicates with Financial Counseling and physicians.
• Manages registration-related communications and educates patients on required documents.
• Participates in staff meetings and pursues continuing education related to scheduling needs.
• Ensures confidentiality of patient records according to HIPAA and compliance policies.

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.
• 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 specialized 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.
• 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 specialized 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.