POSITION SUMMARY:
The Pre-Service Center (PSC) Verification Specialist role belongs to the Revenue Cycle Patient Access team and is responsible for coordinating all financial clearance activities by navigating all pre-registration (to include acquiring or validating patient demographic, insurance, and other required elements along with insurance verification activities), obtaining referral authorization, or precertification number(s), and pre-service cash collections. The role ensures timely access to care while maximizing BMC hospital reimbursement. This role requires adherence to quality assurance guidelines as well as established productivity standards to support the work unit’s performance expectations. This position reports to the Pre-Service Center Supervisor and requires interaction and collaboration with important stakeholders in the financial clearance process, including but not limited to insurance company representatives, patients, physicians, Boston Medical Center (BMC) practice staff, case management, and Patient Financial Counseling. This is a Remote Position.
Position: Pre Service Center (PSC) Specialist
Department: Ambulatory
Schedule: Full Time
ESSENTIAL RESPONSIBILITIES / DUTIES:
Monitors accounts routed to registration, referral, and prior authorization work queues and clears work queues by obtaining all necessary patient and/or payer-specific financial clearance elements in accordance with established management guidelines.
Maintains knowledge of and complies with insurance companies’ requirements for obtaining prior authorizations/referrals, and completes other activities to facilitate all aspects of financial clearance.
Acts as subject matter experts in navigating both the BMC and payer policies to get the appropriate approvals (authorizations, pre-certs, referrals, for example) for the scheduled care to proceed. The PSC Verification Specialist is an important part of the larger patient care team and helps clinicians understand what payer requirements are necessary for the widest possible patient access to services.
Supports BMC staff at all levels for hands-on help in understanding and navigating financial clearance issues.
Uses appropriate strategies to underscore the most efficient process for obtaining insurance verification, authorizations, and referrals, including online databases, electronic correspondence, faxes, and phone calls.
Obtains and clearly documents all referral/prior authorizations for scheduled services prior to admission within the Epic environment.
Works collaboratively with primary care practices, specialty practices, referring physicians, primary care physicians, insurance carriers, patients and any other parties to ensure that required managed care referrals and prior authorizations for specified specialty visits and other services are obtained and appropriately recorded in the relevant practice management systems for patient appointments/visits prior to scheduled patient visits or retro-actively if not in place at the time of the appointment/visit. Ensure that approval numbers are appropriately linked to the relevant patient appointment/visit.
When it is determined that a valid referral does not exist, utilize computer-based tools or contact the appropriate party to obtain/generate referral/authorization and related information. Record the referral/authorization in the practice management system.
Contact internal and external primary care physicians to obtain referral/authorization numbers.
Perform follow-up activities indicated by relevant management reports and WQs.
Collaborates with patients, providers, and departments to obtain all necessary information and payer permissions prior to patients’ scheduled services.
Communicates with patients, providers, and other departments such as Utilization Review to resolve any issues or problems with obtaining required referral/prior authorizations.
Work collaboratively with the practices to resolve registration, insurance verification, referral, or authorization issues to the extent that these unresolved issues impact the ability to obtain a referral/authorization.
Escalates accounts that have been denied or will not be financially cleared as outlined by department policy
Interview patients, families, or referring physicians via telephone in advance of the patient’s appointment/visit whenever possible, to obtain all necessary information, including but not limited to, financial and demographic information required for reimbursement and compliance for services rendered.
Accept registration updates from various intake points, including, but not limited to, paper forms, internet registration forms, practice telephones, and direct calls from patients and facilities.
Ensure that all updated demographic and insurance information is accurately recorded in the appropriate registration systems for primary, secondary, and tertiary insurances.
Review all registration and insurance information in systems and reconcile with information available from insurance carriers. For any insurance updates, utilize any available resources to validate the updated insurance information, insurance plan eligibility, primary care physician, subscriber information, employer information, and appointment/visit information. Contact patients as necessary if clarifications or other follow-up are required, and at all times maintain sensitivity and a clear customer-friendly approach.
For any patient who is new to Boston Medical Center, create a new registration record, accurately obtaining all required data elements, including generating a medical record number, and complete a full registration for the patient.
For self-pay patients or patients with unresolved insurance, and for financial counseling, refer patients to Patient Financial Counseling.
Process current copayments, coinsurance, and/or deductibles for scheduled visits and outstanding patient balances for prior patient accounts during the pre-registration process.
Maintains confidentiality of patients’ financial and medical records; adheres to the State and Federal laws regulating collection in healthcare; adheres to enterprise and other regulatory confidentiality policies; and advises management of any potential compliance issues immediately.
Participates in educational offerings sponsored by BMC or other development opportunities as assigned/available, and complies with all applicable organizational workflows and established policies and procedures.
Demonstrates knowledge & skills necessary to provide a level of customer experience as aligned with BMC management expectations.
Demonstrates the ability to recognize situations that require escalation to the Supervisor.
Establishes relationships and effectively collaborates with revenue cycle staff to support continuous improvement aligned with BMC management expectations as outlined.
Takes the opportunity to know and learn other roles and processes, and works together to assist with process improvement initiatives as directed.
Consistently meets productivity and quality expectations to align performance with assigned roles and responsibilities.
Handle telephone calls in a timely fashion, following applicable scripting and customer service standards. Appropriately manage all calls by either working with the customer or referring the call to the appropriate party.
Regularly undergo Managed Care Quality Audits to achieve the required standard.
Contact the Help Desk in the BMC Information Technology Department to report faulty systems or hardware.
Organize and maintain work area for efficiency, neatness, and safety.
Communicate with all internal and external customers effectively and courteously.
Maintain patient confidentiality, including but not limited to compliance with HIPAA.
Follow established hospital infection control and safety procedures.
Attend all necessary hospital and department training as required.
Perform other related duties as assigned or required.
Must adhere to all of BMC’s RESPECT behavioral standards.
(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required.)
JOB REQUIREMENTS
EDUCATION:
CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:
EXPERIENCE:
KNOWLEDGE AND SKILLS:
Strong customer service skills with sound judgment, independent thinking, creativity, and problem-solving ability
Solid understanding of healthcare insurance (HMO, PPO, authorizations), with knowledge of healthcare terminology and CPT/ICD-10 codes
Excellent verbal and written English communication skills; able to work effectively in complex environments with diverse perspectives
Exceptional interpersonal skills, professionalism, empathy, and the ability to build effective relationships with patients, physicians, staff, and leadership
Comfortable working independently, handling ambiguity, taking initiative, and balancing multiple competing priorities
Close attention to detail with strong decision-making and judgment capabilities
Experience with Epic preferred, including proficiency in Epic workqueues
Strong understanding of Revenue Cycle processes and ability to meet productivity and performance standards
Advanced computer proficiency, including Microsoft Office (Excel, Word, Outlook, Teams) and data entry/interpretation
Team-oriented, able to work cross-functionally, provide backup coverage, and assist throughout the department as needed
Proven ability to handle challenging situations while maintaining strict confidentiality of personal and health information
Compensation Range:
$24.05- $29.31This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, and licensure/certifications directly related to position requirements. In addition, BMCHS offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), contract increases, Flexible Spending Accounts, 403(b) savings matches, earned time cash out, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.
Equal Opportunity Employer/Disabled/Veterans
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