Methodist Physicians Clinic
Perform a variety of duties to determine eligibility and costs for diagnostic procedures and testing. Ensure documentation is current and accurate for payors and clinical staff.
- Verify eligibility and obtain benefit information for diagnostic procedures and testing.
- Provide initial clinical documentation as requested.
- Update demographic and/or insurance information.
- Perform medical necessity check to determine in advance if the procedure or treatment is reasonable and necessary based on diagnosis.
- Document medical necessity checking outcome.
- Generate waiver/ Advanced Beneficiary Notice (ABN) if medical necessity
checking does not meet payer criteria.
- Scan waiver documentation into electronic medical record.
- Ensure notation is made for any documents that require patient signature.
- Accurately screens all applicable Medicare tests.
- Reviews Medicare Secondary Payor (MSP) queries to determine payor for
Medicare and Medicare HMO patients.
- Initiate pre-certification process for diagnostic procedures and testing.
- Ensure all pertinent information is added to electronic medical record
- Clarify orders or documents from providers to ensure that CPT and ICD-10
code is correct for procedure ordered and is authorized.
- Retrieve and submit clinical information.
- Provide communication when additional information is required, eligibility
failed, medical necessity isn’t supported or precertification wasn’t
- Create cost estimates for diagnostic procedures and testing.
- Documents estimated patient responsibility in EMR.
- Ensure all pre-certification, authorization and referral requirements have been completed prior to scheduled procedure.
- Obtain additional clinical information as needed.
- Maintain reference materials to ensure accuracy of information.
- Sets priorities that benefit the department and organizes time to complete
- Can quickly adapt when new processes are introduced and/or existing
processes are modified.
- Maintain productivity and quality standards as defined through the organizational and departmental goals and objectives.
- Participates in mandatory in-services and/or CE programs as mandated by policies and procedures/external agencies and as directed by management.
- Follows and understands the mission, vision, core values, Employee Standards of Behavior and company policies/procedures.
- Other duties as assigned.
Minimum 1 year of clinical experience using electronic medical records required.
- Registration, insurance, or prior-authorization experience preferred.
- Post-Secondary education in a clinical field (e.g., RN, CNA, Radiologist Technologist, Phlebotomist, etc.) or health information management preferred.
- High School or GED required.
Instructions for Resume Submission: