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Tufts Medicine Insurance Verification Coordinator 1 in Tyngsboro, Massachusetts

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Hours: 40 hours per week; Monday through Friday from 8-4:30 or 8:30-5.

Location: Onsite at 100 Potash Hill Rd Tyngsborough, MA 01879. Remote flexibility is a possibility at the discretion of the manager after the individual is trained.

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 entry level role that typically requires little to no prior knowledge or experience, work is routine or follows standard procedures, work is closely supervised, and communicates information that requires little explanation or interpretation.

Job Overview

This position is responsible for obtaining precertification and verification of benefits with all insurance carriers for admissions, surgeries, procedures, studies and/or other clinical services. Responsible for the accurate and complete collection and capture of patient registration data. Reviews and verifies scheduled ambulatory visits for an assigned area, including confirmation that valid insurance coverage exists, that a referral is authorized for specialty visits, and the accuracy of primary care physician data for all managed care patients. Financially secures each account well in advance and escalates financial clearance concerns through prompt and closed-loop communication.

Job Description

Minimum Qualifications :

  1. Associates degree.

  2. Two (2) years of related experience in a hospital, physician office, or financial services.

Preferred Qualifications :

  1. Three (3) years of related experience in a hospital, physician office, or financial services.

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.

  1. Contacts insurance companies to obtain verification of insurance, eligibility, and level of benefits. Enters benefit information into hospital computer systems.

  2. Contacts patients, when necessary, for updates of financial and demographic information. Enters all data into hospital computer systems.

  3. 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.

  4. Arranges for coordination of benefits when more than one insurance carrier is involved.

  5. Updates financial/insurance plan codes within hospital computer systems according to eligibility responses.

  6. 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.

  7. 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.

  8. 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.

  9. Obtains all applicable clinical documentation when required by insurance payers for elective services and submits information to payers within a timely manner.

  10. Closely follow case statuses and communicates and/or documents pending and approved statuses within a timely manner.

  11. Immediately identifies denied claims and works closely with department leaders, coordinators and clinical team members toward their appeal and peer to peer workflow.

  12. Monitors their productivity and quality of workflow directly, reaching days out, productivity, and quality review goals.

  13. Acts as a resource to other departments of the hospital regarding precertification policies and resolution of accounts.

  14. 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.

  15. 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.

  16. 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.

  17. Learns workflow changes and updates as they occur in real-time and maintains an openness to adopt updated workflows.

  18. Assists in the training and shadowing of new team members.

Physical Requirements:

  1. Normal office environment with little exposure to hazardous or unpleasant conditions.

  2. Some mental pressure due to time constraints.

  3. Frequent interaction over the phone, email and online portals through correspondence with payers. Establishes and maintains working relationships with insurance companies to facilitate financial clearance workflow of services.

  4. Frequent interaction with patients regarding issues dealing with confidential medical and financial information.

  5. Daily contact with clinicians, administrative coordinators, department leaders, Patient Access colleagues, Patient Access leadership and other personnel from various departments.

  6. Frequent sitting, occasional standing & walking, lifting 30-35 lbs; medium physical activity including bending, stooping, pushing and pulling.

  7. Requires manual dexterity using fine hand manipulation to operate computer keyboard.

  8. Requires ability to see computer screen and reports.

Skills & Abilities:

  1. Thorough knowledge of medical terminology.

  2. Thorough working knowledge of ICD-10 and CPT coding.

  3. Thorough working knowledge of insurance, payer precertification requirements for in-network, out-of-network, Medicare, and Medicaid.

  4. Thorough working knowledge and willingness to learn computer systems (Microsoft Word/Excel).

  5. Strong verbal and written communication skills. Must demonstrate a patient service focus.

  6. Excellent organizational skills, ability to prioritize work assignments, and attention to detail.

  7. Ability to respond effectively to changing priorities and work processes.

  8. Ability to work independently and also participate in teams within the department and hospital.

  9. Strong customer services skills including excellent interpersonal and telephone skills.

  10. High degree of tact is necessary due to frequent interaction with patients, physicians, and insurance companies.

  11. Through knowledge and understanding of health care delivery systems with special emphasis on the referral management process for managed care providers.

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 careers@tuftsmedicine.org .