Pre-Access Specialist I

CO800 Methodist Physicians Clinic; United States; On-site; USD 42,000 - 65,000; Full time

Job summary

Nebraska Methodist Health System is seeking an Eligibility Specialist to determine eligibility and costs for diagnostic procedures. You will ensure documentation is current for payors and clinical staff, perform medical necessity checks, and manage pre-certification workflows in the EMR environment.

The role emphasizes accurate data entry, communication with providers, and adherence to Medicare/MHP guidelines while supporting efficient patient care processes.

Qualifications

• Education: High School diploma or GED; clinical post-secondary education preferred.
• Experience: 1 year of clinical EMR use and documentation.
• Skills: knowledge of medical terminology, coding basics, and communication.

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 checks for reasonableness and necessity.
• Document medical necessity checks and outcomes.
• Create cost estimates and note patient responsibility in EMR.

Skills

Eligibility

Documentation

EMR

CPT ICD10 coding

Medicare knowledge

Microsoft Office

Education

High School Diploma

Clinical post-secondary education preferred

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 Description

Job Requirements

• Education: High School or GED required. 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 Affirmitive 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.

At Methodist Health System, we focus on providing exceptional care to the communities we serve and the 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.

If you join our organization, you will have the opportunity to excel in your field, use the latest technologies, learn from the best and work as a team. You’ll have the opportunity to make a difference through The Meaning of Care.