Insurance Verification and Authorization Specialist- Homecare

This position is responsible for the verification and documentation of insurance benefits, timely submission of initial prior authorization requests and case management of Homecare patients to ensure that ongoing authorizations are obtained as needed. Responsible for review and preparation of chart documents to accompany complex authorization requests. The Insurance Verification and Authorization Specialist will provide appropriate information to third party payors and communicate with Service Coordinators when additional information is required to assure prior authorization is completed appropriately.

Schedule: (Full time, Benefits Eligible)

Location:

255 East Main Street

The moment you walk through our doors, you feel it. When you meet our patient families, you believe it. And when you talk with anyone who works here, you want to be part of it. Welcome to Nationwide Children’s Hospital, Where Passion Meets Purpose.

Here, Diversity, Equity and Inclusion are integrated into our core values and practices. We are passionate about building, sustaining and evolving an inclusive and equitable environment. We are seeking individuals who live these values and want to share their experiences and efforts in support of our collective mission.

We’re 14,000 strong. And it takes every one of us to improve the lives of the kids we care for, and the kids around the world we’ll never meet. Kids who live healthier, fuller lives because of the knowledge we share. We know it takes a Collaborative Culture to deliver on our promise to provide the very best, innovative care and to foster new discoveries, made possible by the most groundbreaking research. Anywhere.

Ask anyone with a Nationwide Children’s badge what they do for a living. They’ll tell you it’s More Than a Job. It’s a calling. It’s a chance to use and grow your talent to make an impact that truly matters. Because here, we exist simply to help children everywhere.

Nationwide Children’s Hospital. A Place to Be Proud.

• Screens referrals prior to admission for insurance eligibility, coordination of benefits, coverage of requested services and prior authorization requirements. Discusses out of pocket costs with patient/family as appropriate.
• Contacts third party payor to obtain prior authorizations for ordered services, including but not limited to home health, clinical therapies, palliative care, hospice, Home Medical Equipment, enteral nutrition and injectable and infusion medications. This can be completed through payor portals, fax or phone.
• Documents prior authorization appropriately in designated systems and maintains open communication with Homecare service lines whose services need payor approval.
• Collaborates with Service Coordinators and Waiver Case Managers as needed for waivers administered by ODM, ODA and DODD. Obtains initial and ongoing authorizations for waiver services.
• Verifies insurance coverage on a monthly basis for all active Homecare patients.
• Communicates authorization denials and appeal options to patient/family and referral sources. Assists with coverage resources as appropriate.
• Contacts patient/family if insurance cannot be verified and refers self-pay patients to financial assistance resources.
• Reviews and obtains additional prior authorizations as needed when order, scheduling or payor changes are identified. Communicates payor changes to Service Coordinators and billers.
• Maintains record of pending prior authorizations and documents timely follow-up.
• Identifies payor challenges and escalates to Service Coordination and Access Supervisor or Homecare Business Manager as appropriate.
• Provides assistance and additional information requested by Homecare Finance team to assist in billing issues that involve prior authorizations.
• Completes data entry as appropriate to role for Consignment program.
• Ensures that all necessary documentation has been received as applicable to role. Collaborates with Consignment Coordinator as needed to assist with patient referral coordination.
• Assists, as appropriate, in complying with applicable: federal, state and local laws; Medicare / Medicaid Conditions of Participation; Joint Commission standards; State of Ohio Waiver regulations; and any other appropriate accrediting or regulatory body.
• Attends meetings, conferences and in-services to stay up-to-date in knowledge of insurance requirements and regulations
• Participates in drills (including fire, bomb, tornado, weather disaster, community disaster, etc.) and ICES Rounds and follow up, as directed, to ensure the safety of patients, families, staff, students, vendor visitors to the NCHH building, etc.
• Promotes, models, and participates in NCH and NCHH customer service initiatives; fosters patient / parent / caregiver, payor, provider and other community relationships through using effective communication and collaboration skills; and openly and willingly provides NCH staff and managers with customer feedback, in an appropriate and goal-oriented way.
• Actively participates in NCHH continuous quality and performance improvement activities under the direction of the QI Coordinator and respective manager(s) (including event tracking and reporting, patient case conferences, performance improvement teams, customer satisfaction surveys, utilization review activities, etc.)
• Conducts self in a manner that supports good patient relations and projects a professional image consistent with NCH and NCHH standards.
• Maintains at all times the rights of the patient / family regarding confidentiality of the medical record, according to policy.
• Supports the philosophy, mission, policies, procedures, standards, and strategic goals of NCH and NCHH; participates, as directed, in short and long-range planning and NCHH strategic goal development, implementation and evaluation
• Participates in general and department staff meetings, committee work and other related activities as assigned.

• Performs other duties as assigned, including the assumption of new duties commensurate with the growth of the agency.

KNOWLEDGE, SKILLS AND ABILITIES REQUIRED:

Education:

• High school graduate. Associates degree preferred.

Preferred Experience:

• Accounts receivable, billing, managed care and scheduling experience preferred.
• Knowledge of Medicaid, HMO, insurance regulations, and managed care as they affect home care agencies is highly desirable.
• Excellent customer service and communication skills.
• Ability to work and problem solve with minimal supervision.
• Ability to understand and retain complex and quickly changing information.
• Familiar with medical terminology.

Minimum Physical Requirement:

*Note frequency as constantly (67-100%), frequently (34-66%) and occasionally (0-33%) for each requirement.  Also, note any lifting requirements with pound limit.

• Sitting                                                    Frequently     (34 - 66%)
• Talking on the phone / in person           Frequently     (34 - 66%)
• Typing on a keyboard                            Frequently     (34 - 66%)
• Standing / walking                                Occasionally  (00 - 33%)
• Lifts objects weighing up to 30 pounds Occasionally  (00 - 33%)

The above list of duties is intended to describe the general nature and level of work performed by individuals assigned to this classification.  It is not to be construed as an exhaustive list of duties performed by the individual so classified, nor is it intended to limit or modify the right of any supervisor to assign, direct, and control the work of employees under his/her supervision.

EOE/M/F/Disability/Vet