Pre-Access & Eligibility Specialist

Nebraska Methodist Health System; Omaha (NE); Vor Ort; USD 42.000 - 56.000; Vollzeit

Zusammenfassung

Nebraska Methodist Health System in Omaha is seeking a proactive Eligibility Specialist to determine patient eligibility and costs for diagnostic procedures. You will verify benefits, update demographics, and document medical necessity, ensuring accurate payer communications and timely precertification.

The role requires 1 year of clinical experience with EMR systems, strong knowledge of ICD-10/CPT coding, and comfort handling Medicare-related processes.

Qualifikationen

• High School, GED or equivalent combination of education and experience.
• Post-Secondary education in a clinical field (e.g., RN, CNA, Radiologist Technologist, Phlebotomist, etc.) or health information management preferred.

Aufgaben

• Verify eligibility and obtain benefit information for diagnostic procedures and testing.
• Provide initial clinical documentation as requested.
• Update demographic and/or insurance information.
• Perform medical necessity check to determine if the procedure or treatment is reasonable and necessary.
• Document medical necessity checking outcome.
• Generate waiver/ Advanced Beneficiary Notice (ABN) if medical necessity checking does not meet payer criteria.
• Scan waiver documentation into electronic medical record.
• Ensure notation is made for any documents that require patient signature.
• Accurately screens all applicable Medicare tests.
• Reviews Medicare Secondary Payor (MSP) queries to determine payor for Medicare and Medicare HMO patients.
• Initiate pre-certification process for diagnostic procedures and testing.
• Ensure all pertinent information is added to electronic medical record (EMR).
• Clarify orders or documents from providers to ensure that CPT and ICD-10 code is correct for procedure ordered and is authorized.
• Retrieve and submit clinical information.
• Provide communication when additional information is required, eligibility failed, medical necessity isn’t supported or precertification wasn’t approved.
• Create cost estimate for diagnostic procedures and testing.
• Documents estimated patient responsibility in EMR.
• Ensure all pre-certification, authorization and referral requirements have been completed prior to scheduled procedure.
• Obtain additional clinical information as needed.
• Maintain reference materials to ensure accuracy of information.
• Sets priorities that benefit the department and organizes time to complete the tasks.
• Can quickly adapt when new processes are introduced and/or existing processes are modified.
• Maintain productivity and quality standards as defined through the organizational and departmental goals and objectives.

Kenntnisse

Computer skills

Office automation

Verbal communication

Written communication

Medical terminology

Microsoft Office

Medicare knowledge

ICD-10/CPT coding basics

Data entry

Prior-authorization experience

Ausbildung

High School Diploma or GED

Clinical field post-secondary education

Tools

EMR systems

Jobbeschreibung

Nebraska Methodist Health System in Omaha is seeking a proactive Eligibility Specialist to determine patient eligibility and costs for diagnostic procedures. You will verify benefits, update demographics, and document medical necessity, ensuring accurate payer communications and timely precertification.

The role requires 1 year of clinical experience with EMR systems, strong knowledge of ICD-10/CPT coding, and comfort handling Medicare-related processes.