Eligibility Specialist

JOB SUMMARY

The Eligibility Specialist verifies that scheduled procedures are covered by the patient’s insurance or that the patient meets self-pay requirements. They confirm insurance eligibility, benefits, authorizations, and that procedures are approved for the ASC.

They calculate estimated patient financial responsibility, document verification details in the patient accounting system, and complete a Pre-Registration Financial Orientation call to confirm patient information and review expected costs before the date of service.

Education, Experience, and Licensure:

Associate degree or equivalent from a two-year college or technical school; or six months to one year experience in a medical office, hospital, outpatient surgery center, or related field; Computer experience, Excel, Word, Medical Applications; Self-starter, Good Phone etiquette.

Job Requirements:

Verify patient insurance eligibility, benefits, and coverage prior to the date of service. This may require contacting the physician’s office and/or the patient to obtain or clarify necessary information. Ensure the correct primary and secondary insurance payers are selected in the patient accounting system.

Use the center’s designated eligibility vendor and/or payer websites to confirm benefits, authorizations, and pre-certifications as required. Accurately enter insurance information including payer, financial class, electronic billing details, managed care network, and billing address.

Notify management immediately if a patient’s insurance is out of network and follow established policies regarding network participation. Document all verification findings in the patient account.

Contact patients prior to the date of service to review estimated financial responsibility, including co-pays, co-insurance, and deductibles. In accordance with CMS Conditions for Coverage, also review physician ownership, advance directives, and patient rights during the pre-registration call.

Financial Orientation

Calculate and communicate the patient’s estimated financial responsibility based on payer contracts and plan guidelines. Follow established procedures for collecting patient payments including deductibles, co-pays, and co-insurance.

Maintain working knowledge of payer requirements including Medicare, Medicaid, commercial insurance, and workers’ compensation guidelines. Acceptance of in-network benefits for out-of-network payers must be approved by the Urology San Antonio Compliance Department.

Review and communicate the center’s financial policies with patients prior to the date of service.

Clinical Quality

Maintain confidentiality of all patient and facility information in accordance with established policies and HIPAA guidelines.

Document patient information accurately and communicate appropriately with healthcare team members to ensure continuity of care. Interact with patients, families, visitors, and coworkers in a professional and respectful manner to promote a positive facility environment.

Demonstrate a caring and responsive attitude while respecting patient rights and expectations. Ensure communication considers age-specific needs when interacting with patients.

Professional Responsibility & Safety

Utilize time effectively and maintain attendance in accordance with facility policies. Provide appropriate notification for absences or tardiness and request scheduled time off according to departmental procedures.

Complete required documentation accurately and in a timely manner. Adhere to facility safety standards and maintain a clean, organized work area to support a safe environment for patients, staff, and visitors.

Demonstrate proper body mechanics and safe equipment use. Identify and report unsafe conditions to a supervisor and complete required incident or variance documentation according to policy.

Follow infection control guidelines, standard precautions, and universal precautions at all times. Assist with housekeeping tasks when necessary to maintain a safe and professional environment.

Complete financial responsibilities in accordance with facility policy, including accurate patient charge entry and responsible use of resources. Provide input regarding equipment and supply needs as appropriate.

Support and uphold the principles and policies of Urology San Antonio Compliance Program. Perform additional duties as assigned by management.

Continuous Improvement

Participate in staff meetings and review meeting minutes when unable to attend. Take part in scheduled performance evaluations and demonstrate commitment to ongoing professional development and performance improvement.

Promote a positive and collaborative work environment by interacting respectfully with patients, families, physicians, and coworkers. Communicate effectively to address concerns and resolve conflicts when necessary.

Accept constructive feedback and contribute suggestions for improvement in a professional manner. Maintain professional appearance and dress standards according to facility guidelines.

Strive to consistently demonstrate professionalism, courtesy, cooperation, and teamwork.