Denial Prevention Analyst II - REMOTE (Fluent Spanish Preferred)

POSITION SUMMARY:

This position is responsible for ensuring that a patient’s visit is financially secured prior to the date of service. The role includes, but is not limited to, verifying patient insurance eligibility/ benefits, calculating patient liability estimates, securing prior authorization, providing notice of admission, obtaining referrals, and verifying medical necessity. These efforts will result in increased net revenues by reducing front-end related denial write-offs. Interactions will be conducted with providers, payers, patients, and other Steward team members to complete Financial Clearance functions.

KEY RESPONSIBILITIES:

• Verifies eligibility and benefit information through contacting payers or by utilizing various eligibility tools, such as Experian and payer portals
• Performs coverage discovery within Experian’s eligibility tool to identify additional insurance coverage if existing insurance on file is inactive
• Calculates and clearly documents patient liability estimates based on patient’s verified benefit information
• Provides payers with timely inpatient and observation Notices of Admission (NOA) as required based on payer-specific guidelines
• Initiates prior authorization requests via payer portal on behalf of Steward Health providers for applicable service lines as required
• Validates prior authorization has been obtained and follows-up with providers via phone as required for applicable services lines and non-Steward Health providers
• Validates referral has been obtained and follows-up with Steward Health and non-Steward Health providers for applicable service lines as required
• Verifies medical necessity for applicable patients and identifies instances where a Medicare Advance Beneficiary Notices of Noncoverage (ABN) is required
• Ensures Financial Clearance (e.g., verification of eligibility/ benefits, securing prior authorization, etc.) is obtained timely prior to patient’s DOS based on service line and departmental policies
• Escalates instances where Financial Clearance may not be obtained (e.g., unable to obtain authorization) prior to patient’s DOS to appropriate stakeholders in accordance with departmental deferral policies
• Resolves insurance coverage and authorization information discrepancies as identified through automated quality assurance tool (Experian’s RQA)
• Works denials related to referral, authorizations, notifications, non-coverage, and medical necessity as assigned. This includes, but is not limited to, coordinating with appropriate stakeholders to submit rebills or appeals and obtaining retro authorization when required
• Observes privacy, safety, and security procedures, and uses equipment and materials properly
• Works cohesively with other team members to achieve departmental goals
• Completes assigned tasks effectively and within stipulated deadlines

REQUIRED KNOWLEDGE & SKILLS:

• Fluent in English required; Fluent in Spanish preferred
• Excellent customer service and communication skills (verbal and written)
• Displays understanding of Revenue Cycle functions, flow, and operations
• Competent in core math skills required (determined by obtaining satisfactory score on competency exam)
• Experience level will also be a factor in lieu of educational requirements

EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:

1. Education: High School diploma or GED required
2. Experience: 1-2 years’ experience in dynamic healthcare (clinic, physician, or hospital setting) or payer environment preferred
3. Software/Hardware: Comfort with data entry using Revenue Cycle software, patient management systems, and Windows-based applications preferred; experience using Microsoft Office applications such as Excel and Word a plus