Patient Access Quality Specialist

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates.

The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time).

Pay Range:

Scheduled Weekly Hours:

Position Overview

SUMMARY (Basic Purpose of the Job):

Provides technical and analytical support for Patient Access registration analysis and evaluation in performance improvement process. Performs chart review in identifying if variation from quality of registration exists. Monitors patient registrations for accuracy, compliance, and responsibility.

MINIMUM REQUIREMENTS:

Education: High school diploma or equivalent.

Experience: Three years Patient Access department experience.

Knowledge and Skills: Ability to effectively communicate information and respond to questions in person-to-person and small group situations with customers, clients, general public and other employees of the organization.

Special Training: Excellent understanding of insurance concepts and health plan policies. Knowledge in all areas of hospital registration and authorizations.

Mental, Behavioral and Emotional Abilities: Ability to deal with problems involving several known variables in situations of a routine nature.

ESSENTIAL FUNCTIONS:

• Comprehends registration requirements and applies it during chart review. Perform chart review to identify if variation from quality registrations exists, and to determine the need for process improvement. Identify concerns and make recommendations for review to improve processes. Communicate findings as appropriate to department management involved. Reports discrepancies to supervisor/manager to ensure corrective action is taken in a timely manner.

• Maintains complete knowledge of registration system and department operational procedures and training guidelines to identify and have the ability to audit charts for accurate demographic, diagnosis, and insurance information for all registrations.

• Maintains complete knowledge and understanding of department procedure to guarantee proper registrations for Trauma, Doe, Pre-hospital stroke, Neuro, Cardiac Cath registration, downtime and disaster processes.

• Provides staff coverage as needed. Assists with development and implementation of new or improved processes. Maintains up to date knowledge with Insurance matrix, registration compliance, insurance applications, other systems utilized by Patient Access.

• Utilizes excellent communication skills, ability to communicate, and obtain additional patient information, scripts, referrals, authorization from physicians and other customers.

• Possesses proficiency with all insurance plans and payer codes. Ability to identify payment source and to secure all information required to insure a billable and collectable account and avoid penalties, denials prior to the bill dropping.

• Maintains thorough understanding of payor requirements for authorization, pre-authorization, referrals, coordination of benefits forms, and in-network verification according to department procedures and the Insurance Card Database and Insurance Verification guidelines. Performs verification of benefits either electronically or by telephone according to department procedures and guidelines. Identifies and obtains required precertification, authorizations and/or referrals and audits all information in the appropriate registration and billing system.

• Possesses ability to understand and use audit reports for missing vital billing information.

• Reviews coordination of benefits, and Medicare secondary payor guidelines to determine primary and secondary payer status, Advance Beneficiary Notice, Advance Directives, and Patients' Rights forms.

• Assists with development and implementation of new or improved processes. Maintains knowledge and is proficient with all insurance verification and authorization application, electronic medical record, medical necessity, Cerner registration functions, and other systems utilized by Patient Access.

• Provides ongoing performance feedback, addresses problems, and assists with departmental training of new employees. Verifies and documents competency and identifies and suggests ways to develop skills.

• Communicates new insurance rules, changes in policies, procedures and regulations.

• Monitors compliance with regulatory, licensing, and accreditation standards. Facilitates quality improvement by reporting problems, concerns, and opportunities for increased revenue and decreased denials.

• Performs any other related duties as required or assigned.

PHYSICAL DEMANDS AND WORK ENVIRONMENT:

• Frequent physical demands include: Sitting , Standing , Walking

• Occasional physical demands include: Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Squat/kneel/crawl , Wrist position deviation , Keyboard use/repetitive motion

• Continuous physical demands include: Talk or Hear

• Lifting Floor to Waist 15 lbs. Lifting Waist Level and Above 10 lbs.

• Sensory Requirements include: Very Accurate 20/40, Near Vision, Very Accurate 20/40, Far Vision, Color Discrimination, Minimal Depth Perception, Accurate Hearing

• Anticipated Occupational Exposure Risks Include the following: Bloodborne Pathogens , Airborne Communicable Disease , Dust/Particulate Matter

This position is eligible for the following benefits:

• Medical Plan

• Prescription drug coverage & In-House Employee Pharmacy

• Dental Plan

• Vision Plan

• Flexible Spending Account (FSA)

- Healthcare FSA

- Dependent Care FSA

• Retirement Savings and Investment Plan

• Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance

• Supplemental Group Term Life & Accidental Death & Dismemberment Insurance

• Disability Benefits – Long Term Disability (LTD)

• Disability Benefits – Short Term Disability (STD)

• Employee Assistance Program

• Commuter Transit

• Commuter Parking

• Supplemental Life Insurance

- Voluntary Life Spouse

- Voluntary Life Employee

- Voluntary Life Child

• Voluntary Legal Services

• Voluntary Accident, Critical Illness and Hospital Indemnity Insurance

• Voluntary Identity Theft Insurance

• Voluntary Pet Insurance

• Paid Time-Off Program

The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level. 

The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.