Pre-Service Center Verification Specialist

📋 Description

• • Join BMC Software, Inc. as a Pre-Service Center (PSC) Verification Specialist and become a pivotal member of our Revenue Cycle Patient Access team. In this fully remote role, you will be instrumental in coordinating all financial clearance activities, ensuring seamless access to care for our patients while maximizing reimbursement for BMC hospitals.
• • Your primary responsibility will involve navigating the intricate pre-registration process. This includes meticulously acquiring or validating essential patient demographic and insurance information, securing necessary referral authorization or precertification numbers, and facilitating pre-service cash collections. You will be the frontline in ensuring that patients are financially cleared before their scheduled services, minimizing potential disruptions and financial burdens.
• • This role demands a keen eye for detail and a commitment to quality. You will be expected to adhere strictly to established quality assurance guidelines and meet defined productivity standards, contributing directly to the overall performance and success of the work unit.
• • You will report to the Pre Service Center Supervisor and will engage in crucial interactions and collaborations with a diverse range of stakeholders. This includes, but is not limited to, insurance company representatives, patients, physicians, BMC practice staff, case management, and Patient Financial Counseling. Building and maintaining strong working relationships with these groups is essential for efficient operations.
• • A core function of your role will be to monitor accounts routed to registration, referral, and prior authorization work queues. You will proactively clear these queues by obtaining all required patient and/or payer-specific financial clearance elements, strictly in accordance with established management guidelines. This requires a proactive and organized approach to managing a high volume of tasks.
• • You must maintain up-to-date knowledge of and strictly comply with the specific requirements of various insurance companies for obtaining prior authorizations and referrals. Your expertise will ensure that all necessary activities are completed to facilitate comprehensive financial clearance for scheduled services.
• • You will serve as a subject matter expert in navigating both BMC and payer policies. Your ability to understand and apply these policies will be critical in obtaining the appropriate approvals (authorizations, pre-certs, referrals) necessary for scheduled care to proceed. You are an integral part of the patient care team, helping clinicians understand payer requirements to ensure the widest possible patient access to services.
• • Provide hands-on support and guidance to BMC staff at all levels, assisting them in understanding and navigating complex financial clearance issues. Your expertise will empower colleagues and streamline processes.
• • Employ a variety of effective strategies to ensure the most efficient process for obtaining insurance verification, authorizations, and referrals. This includes leveraging online databases, electronic correspondence, faxes, and direct phone calls to gather and confirm information.
• • Accurately obtain and clearly document all referral and prior authorizations for scheduled services within the Epic environment, ensuring this is completed prior to patient admission whenever possible.
• • Work collaboratively with primary care practices, specialty practices, referring physicians, primary care physicians, insurance carriers, patients, and other relevant parties. Your goal is to ensure that all required managed care referrals and prior authorizations for specified specialty visits and other services are obtained and appropriately recorded in the relevant practice management systems before scheduled patient visits. You will also handle retroactive authorizations when necessary.
• • When a valid referral is not found, you will utilize computer-based tools or contact the appropriate party to obtain or generate the necessary referral/authorization and related information, ensuring it is accurately recorded in the practice management system.
• • Proactively contact internal and external primary care physicians to obtain referral/authorization numbers, ensuring a smooth and timely process.
• • Perform diligent follow-up activities as indicated by relevant management reports and work queues, ensuring no account falls through the cracks.
• • Collaborate effectively with patients, providers, and various departments, such as Utilization Review, to resolve any issues or problems encountered in obtaining required referral/prior authorizations.
• • Work in tandem with practices to resolve registration, insurance verification, referral, or authorization issues that impede the ability to obtain necessary approvals.
• • Escalate accounts that have been denied or will not be financially cleared according to established department policies and procedures.
• • Conduct telephone interviews with patients, families, or referring physicians in advance of appointments whenever feasible. The objective is to gather all necessary financial and demographic information required for reimbursement and compliance for services rendered.
• • Accept and process registration updates from various intake points, including paper forms, online registration forms, practice-based telephones, and direct patient calls.
• • Ensure all updated demographic and insurance information is accurately recorded in the appropriate registration systems for primary, secondary, and tertiary insurances.
• • Meticulously review all registration and insurance information within the systems, reconciling it with data available from insurance carriers. For any insurance updates, utilize all available resources to validate the information, including plan eligibility, PCP, subscriber details, employer information, and appointment specifics. Maintain a sensitive, customer-friendly approach when contacting patients for clarifications or follow-up.
• • For new patients to Boston Medical Center, create accurate registration records, obtaining all required data elements, generating medical record numbers, and completing a full registration.
• • Refer patients to Patient Financial Counseling when they are self-pay, have unresolved insurance issues, or require financial guidance.
• • Process current copayments, coinsurance, and/or deductibles for scheduled visits, as well as outstanding patient balances for prior accounts, during the pre-registration process.
• • Uphold the strictest confidentiality of patient financial and medical records, adhering to all State and Federal laws regulating healthcare collections, as well as enterprise and other regulatory confidentiality policies. Immediately advise management of any potential compliance issues.
• • Actively participate in educational offerings and development opportunities sponsored by BMC, complying with all applicable organizational workflows, policies, and procedures.
• • Demonstrate the knowledge and skills necessary to provide a high level of customer experience, aligning with BMC management expectations.
• • Exhibit the ability to recognize situations requiring escalation to the Supervisor, ensuring timely and appropriate resolution.
• • Foster strong relationships and collaborate effectively with revenue cycle staff to support continuous improvement initiatives aligned with BMC management expectations.
• • Proactively seek opportunities to learn other roles and processes, working collaboratively to assist with process improvement initiatives as directed.
• • Consistently meet productivity and quality expectations, ensuring performance aligns with assigned roles and responsibilities.
• • Handle telephone calls efficiently, adhering to applicable scripting and customer service standards. Appropriately manage all calls by either resolving the customer's needs or referring them to the correct party.
• • Regularly participate in Managed Care Quality Audits to achieve the required standard, demonstrating a commitment to accuracy and compliance.
• • Report any faulty systems or hardware to the Help Desk in the BMC Information Technology Department, notifying your supervisor if issues are not addressed promptly. Contact the appropriate vendor or department for equipment servicing and inform your supervisor.
• • Organize and maintain your work area for optimal efficiency, neatness, and safety.
• • Communicate effectively and courteously with all internal and external customers.
• • Maintain patient confidentiality, including strict compliance with HIPAA regulations.
• • Follow all established hospital infection control and safety procedures.
• • Attend all necessary hospital and department training sessions as required.
• • Perform other related duties as assigned or required.
• • Adhere to all of BMC’s RESPECT behavioral standards.