Patient Access Specialist - Remote

Location: Fully remote after 2-3 weeks of onsite training at 847 Rogers St. Lowell, Massachusetts.

Hours: 40 hours per week. Rotating weekend & holiday requirement.

Shift: Saturday through Wednesday from 8:30 AM to 5:00 PM.

Job Profile Summary

This role focuses on activities related to revenue cycle operations such as billing, collections, and payment processing. In addition, this role focuses on performing the following Patient Access duties: Performs the administrative and financial-clearance duties necessary to facilitate the procurement of clinical services by patients. Collects patient's necessary demographic and financial information from physician offices, acute-care entities, or the patients themselves, schedules services for patients, and handles referrals from primary care doctors to ensure patients are scheduled for recommended appointments/procedures, etc. An organizational related support or service (administrative or clerical) role or a role that focuses on support of daily business activities (e.g., technical, clinical, non-clinical) operating in a “hands on” environment. The majority of time is spent in the delivery of support services or activities, typically under supervision. An experienced level role that requires basic knowledge of job procedures and tools obtained through work experience and may require vocational or technical education. Works under moderate supervision, problems are typically of a routine nature, but may at times require interpretation or deviation from standard procedures, and communicates information that requires some explanation or interpretation.

Job Overview

This position is responsible for obtaining complex precertification and verification of benefits with all insurance carriers for inpatient admissions, outpatient and day surgeries, transplant services, GI procedures, radiology services, sleep studies and/or echocardiograms. Financially secures each account well in advance and escalates financial clearance concerns through prompt and closed-loop communication. Collaborates and reviews financial clearance data to ensure proper authorization for all services. Position focuses on complex pre-certification duties, including denial and appeal workflow, and acts as a resource for the Patient Access team.

Job Description

Minimum Qualifications:

• Four (4) years of related experience in a hospital, physician’s office or financial setting.
• Pre-certification experience
  
  
  

Preferred Qualifications:

• Five (5) years of related experience in a hospital, physician’s office or financial setting.
• Associate’s degree.
  
  
  

Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.

• Contacts insurance companies to obtain verification of insurance, eligibility, and level of benefits. Enters benefit information into hospital computer systems.
• Contacts patients, when necessary, for updates of financial and demographic information. Enters all data into hospital computer systems.
• Obtains financial data from a variety of sources including both in-state and out-of-state payers. Utilizes computer systems, payer eligibility sites & phone outreach.
• Arranges for coordination of benefits when more than one insurance carrier is involved.
• Updates financial/insurance plan codes within hospital computer systems according to eligibility responses.
• Seeks clinical approval of admission (precertification) for surgeries, admissions, procedures, imaging and all other in-scope services. Enters precertification information and proper documentation into hospital computer systems.
• Identifies procedures & services that are not covered services by individual insurance policies. Refers all identified financial risk concerns to the department, Patient Access leadership for immediate review and resolution.
• Collaborates with Financial Coordination colleagues regarding patients with identified financial risk concerns for resolution prior to services being rendered. Suggests postponement of elective services until financial arrangements are in place.
• Obtains all applicable clinical documentation when required by insurance payers for elective services and submits information to payers within a timely manner.
• Closely follow case statuses and communicates and/or documents pending and approved statuses within a timely manner.
• Identifies denied claims and works closely with department leaders, coordinators and clinical team members toward their appeal and peer to peer workflow.
• Monitors their productivity and quality of workflow directly, reaching days out, productivity, and quality review goals.
• Acts as a resource to other departments of the hospital regarding precertification policies and resolution of accounts.
• Communicates clearly to team members and leadership status of financially at-risk cases and resolution steps. Closely monitors at risk cases and provide timely updates.
• Maintains collaborative, team relationships with peers and colleagues in order to effectively contribute to the working group’s achievement of goals, and to help foster a positive work environment.
• Works closely with Case Management and Admitting colleagues to confirm level of care changes, particularly for unplanned or urgent admissions, and communicate level of care upgrades or downgrades with payers within a timely manner.
• Learns workflow changes and updates as they occur in real-time and maintains an openness to adopt updated workflows.
• Assists in the training and shadowing of new team members. Works closely with supervisor & manager to create and support training schedule and resources.
• Works closely with Revenue Cycle colleagues to complete root cause analysis on complex denials and formally appeal denials within a timely manner. Includes the creation and close organization of appeal letters and reconsideration requests.
• Acts as a resource for the team, sharing payer updates, participating in cross-department meetings and actively participate in Pre-certification Team Meetings.
• Assists Manager with coverage if supervisor is out of the office; including worklist management, review of at-risk cases, and closed loop communication to department leaders re: non-financially secure cases.
  
  
  

Physical Requirements:

• Professional office environment with typical office requirements such as computers, phones, photocopiers, filing cabinets, etc.
• This is largely a sedentary role, which involves sitting most of the time, but may involve movements such as walking, standing, reaching, ascending / descending stairs and operate office equipment.
• Frequently required to speak, hear, communicate and exchange information.
• Able to see and read computers displays, read fine print, and/or normal type size print and distinguish letters, numbers and symbols.
• Occasionally lift and/or move up to 25 pounds.
  
  
  

Skills & Abilities:

• Thorough knowledge of medical terminology.
• Thorough working knowledge of ICD-10 and CPT coding.
• Thorough working knowledge of payer precertification requirements and in-network and out-of-network payers.
• Thorough working knowledge and willingness to learn computer systems.
• Strong verbal and written communication skills. Must demonstrate a patient service focus.
• Excellent organizational skills and ability to prioritize work assignments. Ability to respond effectively to changing priorities and work processes.
• Strong leadership and team collaboration skills.
• Ability to work independently and also participate in teams within the department and hospital.
  
  
  

Tufts Medicine is a leading integrated health system bringing together the best of academic and community healthcare to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. Comprised of Tufts Medical Center, Lowell General Hospital, MelroseWakefield Hospital, Lawrence Memorial Hospital of Medford, Care at Home - an expansive home care network, and large integrated physician network. We are an equal opportunity employer and value diversity and inclusion at Tufts Medicine. Tufts Medicine does not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity and/or expression, marital status or any other characteristic protected by federal, state or local law. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation by emailing us at [email protected].