Job Description
1.0FTE
The Insurance Verification Representative reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.
- The Insurance Verification Representative confirms accuracy of and verifies insurance benefits for non-government payers (managed care) on new patients for the Wheaton inpatient acute and sub-acute programs. Pre-certifies with insurance or obtains case management or insurance adjuster's approval for planned services or procedures. Uses the pre-determination process to determine coverage for procedures in question. Provides detailed information to admissions staff, clinical referral liaisons, case managers, nursing staff and physicians when appropriate. Discusses financial responsibility with pending patients as needed.
RESPONSIBILITIES:
Obtains and coordinates preliminary case management authorization.
- Coordinates information from the patient, physicians and office staff, clinical referral liaisons and employers as needed to and complete the verification process.
- Obtains third-party pre-certification and concurrent review information and communicates to the admissions staff, clinical referral liaisons, case managers, appropriate physician departments and payer representatives.
- Communicates any changes in patient's clinical status to third-party payer to ensure authorization is current and accurate and provides notice of patient admission into the facility.
- Keeps insurance verification tracking log current and available to admissions staff and clinical referral liaisons with the most up-to-date status of patients in the verification queue.
- Communicates situations projected to result in a significant non-covered balance to the department director.
- Communicates corrected information and acts as a resource to admissions staff, clinical referral liaisons, case managers and others regarding contract guidelines and pre-certification requirements.
- Notifies admissions staff, clinical referral liaisons and department director when medical review is required.
- Reviews and analyzes financial information from third party payer systems and communicates that information to the business office and appropriate servicing department.
- Keeps up-to-date on trends and issues that affect reimbursement.
- Performs verification/certification function using alternative processes in case of downtime or disaster.
- Tracks and records insurance denial trends, and manages the appeal process on behalf of patients.
Collects accurate financial data and enters into Meditech
- Works with admissions staff, clinical referral liaisons, case managers and other departments ensuring financial data integrity is maintained and critical elements are reflected in the patient record.
- Maintains a strong customer focus while working collaboratively within a team to meet multiple demands, patient needs and coverage.
- Maintains confidentiality of all information.
- Suggests quality improvement ideas and participates in education and improvement efforts.
Provides communication to patients, patient financial services, and case managers on insurance findings
- Contacts patients, guarantor and business offices to inform of financial responsibility and attempts to coordinate financial arrangement.
- Produces projected benefit letters for patients and acts as a point person for counseling.
- Communicates benefit detail to admissions staff, clinical referral liaisons and case managers to ensure notification and collection of co-pays, deductibles and outstanding balances.
- Coordinates additional information requests as may be necessitated by third party administrators.
Qualifications
Required:
- High School or Equivalent (GED)
- Knowledge of medical, insurance terminology, and ICD codes is required.
- Ability to understand and communicate financial information.
- Highly proficient computer skills preferred.
- Ability to work independently.
- Excellent communication skills are required.
- Strong customer service focus is essential.
- Resourceful with problem solving.
- Well organized and efficient.
- Required to demonstrate proper telephone customer skills.
- Must be able to perform multiple tasks with composure and confidence.
- Ability to maintain composure under pressure.
Preferred:
- Three to four years of health- related experience
- Associate or Bachelors Degree
Additional Information
Northwestern Medicine is an equal opportunity employer (disability, VETS) and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status.
Background Check
Northwestern Medicine conducts a background check that includes criminal history on newly hired team members and, at times, internal transfers. If you are offered a position with us, you will be required to complete an authorization and disclosure form that gives Northwestern Medicine permission to run the background check. Results are evaluated on a case-by-case basis, and we follow all local, state, and federal laws, including the Illinois Health Care Worker Background Check Act.
Artificial Intelligence Disclosure
Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person.
Benefits
We offer a wide range of benefits that provide employees with tools and resources to improve their physical, emotional, and financial well-being while providing protection for unexpected life events. Please visit our Benefits section to learn more.
Sign-on Bonus Eligibility: Internal employees and rehires who left Northwestern Medicine within 1 year are not eligible for the sign on bonus. Exception: New graduate internal employees seeking their first licensed clinical position at NM may be eligible depending upon the job family.
