Insurance Eligibility Specialist - Hospital Pre-Access

DHR Health; McAllen (TX); On-site; USD 36,000 - 48,000; Full time

Job summary

DHR Health in McAllen, Texas seeks an Insurance Verifier for Pre-Access Services to review insurance information and determine eligibility for registration. The role involves collecting patient demographics, verifying coverage, obtaining pre-certifications, and communicating with third-party payers.

Requirements include a high school diploma or GED and at least one year of billing experience, with hospital claims exposure preferred. Strong communication and computer skills are essential.

Qualifications

• High school diploma or GED required.
• One year billing experience required.
• Experience in claims filing, hospital setting preferred.
• Good written and verbal communication skills required.
• Ability to read, write and speak English.
• Ability to communicate clearly and concisely with all levels of nursing, administration, and physicians.
• Secretarial experience is required.
• Must possess working knowledge of personal computers and software applications used in job.

Responsibilities

• Promotes the facility mission, vision and values by effectively communicating them to others.
• Determines hospital privileges of physician attending patient by checking the listing of active medical staff.
• Determines financial status and eligibility for registration by reviewing Insurance information.
• Obtains patient demographic information, type of insurance, diagnosis and procedure requested.
• Explains rates, charges, services when applicable, and hospital policy regarding payment of bills.
• Communicates information about scheduled case procedure to various departments and personnel involved.
• Obtains patient’s insurance information, including benefit information, policy number, group name, group number.
• Obtaining pre-certification approval when needed.
• Calling third party payer to obtain effective dates of coverage, billing addresses, existing condition clauses and network information.
• Confirms billing address, pre-existing conditions, in and out of network benefits and maximum coverage.
• Utilizes phone or on-line verification systems, i.e. TMHP, IVANS, FISS and Availity, etc for insurance eligibility and benefits.
• Ensures referral/pre-authorization requirements have been met.
• Obtains date of injury, compensable bodily injury, adjuster’s name, onset of illness and claim number for worker’s compensation.
• Verify and assign appropriate insurance plan code as needed.
• Document clearly and concisely all patient information on accounts through the patient accounting system (Account notes section, Aeos system, pre-cert screen).
• Demonstrates proficiency of personal computers and Microsoft Office applications and other software as required.
• Ensures patient confidentiality requirements are met in accordance with HIPAA/PHI policies and procedures.
• Ability to reference ICD-9 CM/ICD-10 CM, CPT from doctor’s order to insurance carrier for eligibility and coverage of procedure.
• Start Retro cases for patient’s accounts that do not have authorization before the exam was done.
• Call doctor’s offices to obtain clinical information to fax to the insurance office for the Retro cases.
• Obtain pre-authorizations for Radiology procedures for physicians that request it.
• Ensures that all accounts for the next day are verified.
• Other duties as assigned.

Skills

Communication skills

English proficiency

Computer skills

Professional image

Organizational skills

Independent judgment

Education

High school diploma or GED

Job description

DHR Health in McAllen, Texas seeks an Insurance Verifier for Pre-Access Services to review insurance information and determine eligibility for registration. The role involves collecting patient demographics, verifying coverage, obtaining pre-certifications, and communicating with third-party payers.

Requirements include a high school diploma or GED and at least one year of billing experience, with hospital claims exposure preferred. Strong communication and computer skills are essential.