Pre-Access Specialist I

Nebraska Methodist Health System; Omaha (NE); On-site; USD 42,000 - 56,000; Full time

Job summary

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.

Qualifications

• 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.

Responsibilities

• 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.

Skills

Computer skills

Office automation

Verbal communication

Written communication

Medical terminology

Microsoft Office

Medicare knowledge

ICD-10/CPT coding basics

Data entry

Prior-authorization experience

Education

High School Diploma or GED

Clinical field post-secondary education

Tools

EMR systems

Job description

Why work for Nebraska Methodist Health System?

At Nebraska Methodist Health System, we focus on providing exceptional care to the communities we serve and people we employ. We call it The Meaning of Care – a culture that has and will continue to set us apart. It’s helping families grow by making each delivery special, conveying a difficult diagnosis with a compassionate touch, going above and beyond for a patient’s needs, or giving a high five when a patient beats a disease or conquers a personal health challenge. We offer competitive pay, excellent benefits and a great work environment where all employees are valued! Most importantly, our employees are part of a team that makes a real difference in the communities we live and work in.

Job Summary

Location: Methodist Corporate Office

Address: 825 S 169th St. - Omaha, NE

Work Schedule: Mon - Fri, 8:00am to 4:30pm

Perform a variety of duties to determine eligibility and costs for diagnostic procedures and testing. Ensure documentation is current and accurate for payors and clinical staff.

Responsibilities

Essential Job Functions

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 in advance if the procedure or treatment is reasonable and necessary based on diagnosis.

• 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.

Schedule

Mon - Fri, 8:00am to 4:30pm

Job Requirements

Education

• 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.

Experience

• Minimum 1 year of clinical experience using electronic medical records required.
• Registration, insurance, or prior-authorization experience preferred.

License/Certifications

• N/A

Skills/Knowledge/Abilities

• Skill using computers and office equipment.
• Skill organizing and prioritizing work.
• Skill with verbal and written communication.
• Knowledge of medical terminology.
• Knowledge of Microsoft Office suite.
• Knowledge of Medicare requirements.
• Basic knowledge of ICD 10/CPT coding.
• Ability to perform mathematical calculations.
• Ability to adhere to all workplace and safety requirements, regulations, standards, and practices

Physical Requirements

Weight Demands

• Light Work - Exerting up to 20 pounds of force.

Physical Activity

• Not necessary for the position (0%):
  • Climbing
  • Crawling
  • Kneeling
• Occasionally Performed (1%-33%):
  • Balancing
  • Carrying
  • Crouching
  • Distinguish colors
  • Lifting
  • Pulling/Pushing
  • Standing
  • Stooping/bending
  • Twisting
  • Walking
• Frequently Performed (34%-66%):
  • Fingering/Touching
  • Grasping
  • Keyboarding/typing
  • Reaching
  • Repetitive Motions
  • Sitting
  • Speaking/talking
• Constantly Performed (67%-100%):
  • Hearing
  • Seeing/Visual

Job Hazards

• Not Related:
  • Chemical agents (Toxic, Corrosive, Flammable, Latex)
  • Biological agents (primary air born and blood born viruses) (Jobs with Patient contact) (BBF)
  • Physical hazards (noise, temperature, lighting, wet floors, outdoors, sharps) (more than ordinary office environment)
  • Equipment/Machinery/Tools
  • Explosives (pressurized gas)
  • Electrical Shock/Static
  • Radiation Alpha, Beta and Gamma (particles such as X-ray, Cat Scan, Gamma Knife, etc)
  • Radiation Non-Ionizing (Ultraviolet, visible light, infrared and microwaves that causes injuries to tissue or thermal or photochemical means)
  • Mechanical moving parts/vibrations

About Methodist

Nebraska Methodist Health System is made up of four hospitals in Nebraska and southwest Iowa, more than 30 clinic locations, a nursing and allied health college, and a medical supply distributorship and central laundry facility. From the day Methodist Hospital was chartered in 1891, service to our communities has been a top priority. Financial assistance, health education, outreach to our diverse communities and populations, and other community benefit activities have always been central to our mission.

Nebraska Methodist Health System is an Affirative Action/Equal Opportunity Employer and does not discriminate on the basis of race, color, religion, sex, age, national origin, disability, veteran status, sexual orientation, gender identity, or any other classification protected by Federal, state or local law.