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CCS Admitting Representative

Administrative | Emeryville, CA | Full Time and Contract

Job Description

CCS Admitting Representative 753623 

The California Children’s Services (CCS) Authorization Representative is individually accountable for securing treatment authorizations for the CCS patient population that includes inpatient admissions and ancillary outpatient services. The CCS Unit is responsible for meeting organizational financial targets of approximately $22 million each week for CCS DNB (Discharged Not Billed) patient accounts.  Collectively, the CCS Authorization Representative team contributes to timely and appropriate patient access and service for CCS covered conditions.   The scope of work that the Authorization Representative is responsible for requires ongoing account analysis, consistent communication of technical medical language and unique patient accounts and CCS coverage guidelines and billing knowledge.

The primary responsibility of the CCS Authorization Representative is to communicate patient services authorization requests with all CCS service area counties, for the approximate 58 counties throughout the State of California and requesting authorizations by submitting Service Authorization Request (SAR) forms. The CCS Authorization Representative works closely with case managers and ordering providers’ office staff and external clinical professionals.  On occasion and in conjunction with the unit supervisor, may interact with State Medical Directors to resolve individual account authorization or coverage issues.  In general, the CCS Authorization Representative is responsible for all aspects of financially securing CCS insurance and authorization data for patient services. The CCS Authorization Representative’s responsibilities include, though are not limited to: 1) verifying demographic and clinical information relevant to the patient’s visit 2) verifying insurance eligibility and benefits, 3) securing authorizations, and 4) properly notating all activity in the APeX electronic health record system.

Responsibilities:

  • Independently accountable and responsible for obtaining authorizations for all CCS population for inpatient admissions, outpatient surgeries/procedures and outpatient visits or services by working with ordering physician’s office , the applicable Medical Center department, and/or review organization(s).
  • Confirms Medi-Cal eligibility and provides notification for established patients or initiates new patient referrals to CCS for inpatient admissions, outpatient surgery and procedures analyzing and identifying appropriate CPT (Current Procedure Terminology) procedural codes and ensuring that CCS insurance coverage is properly attached and documented in the electronic  health record (APeX system).  The Account Representative utilizes their specialized knowledge of insurance billing and reimbursement to maximize the return to the Enterprise.   In the event that the inpatient admission or outpatient surgical procedures are rescheduled due to an authorization issue, protocol change, patient request, or any other event, the CCS Authorization Representative will ensure that all parties are informed including communicating with the provider’s office to ensure that proper follow up is maintained.
  • Confirm patient’s complete insurance eligibility and benefits identifying any specific concerns that may delay the ability to secure authorization and update APeX or authorization request as necessary.  This may include insurance coverage available and confirmed when CCS eligibility is verified on Medi-Cal website.  
  • Retrieves clinical information, completes appropriate forms and submits authorization requests for CCS population ordered by company clinicians via patient work queues, Right Fax automated fax system, online submission, emails or telephone. Independently follows patient authorization determination and responds appropriately to provide additional information to all parties involved, monitors authorization status and updates referral status as needed.
  • As needed, contact patient or patient’s representative to collect and confirm current patient demographic information and financial/insurance data and update the patient’s account in order to submit treatment authorization requests accurately and in the most financially beneficial method available. Update any deficiencies in patient registration information and document all identified pertinent information received.
  • Utilizing Real-Time Eligibility (RTE), government-sponsored program web sites, and Hospital Account Record (HAR) notes identifies whether patient’s primary insurance coverage is either an HMO or PPO in order to determine whether patient is eligible to be referred to CCS for possible eligibility (qualification criteria: family’s financial responsibility is 20% or greater of customary charges).
  • Communicates with physician staff, clinics, internal and external case management and pre-access department when authorization referral remains in “Pending” status or not submitted for review. Clinics request status update when accounts remain pending or no update has been received
  • Independently initiates communication with ordering physician, Billing entities, Pre-Access, and patients regarding the authorization denial status.  Appeals to CCS may be an option at this point by providing more medical records. CCS staff receive Notice of Action (NOA) denials and upload in APeX Media Manager. For inpatient admissions, CCS coverage is removed from HAR and secondary set to A02 account status for follow up as established in NOA workflow document  (November 2016).  CCS Authorization Unit Representative will provide notification upon request by clinics
  • Conducts reviews and facilitates claim edit audits for requests for information (RFI's) within APeX system from billing groups to facilitate claims and proper billing.   Resolving claim edits is necessary for account payment and resolution
  • Submits CCS applications received from Social Services and other departments to assist in the facilitation of the application process for patients to receive CCS-associated services.   Follows referral workflow implemented in conjunction with Social Services Department.
  • Reports all non-CCS-paneled clinicians to supervisor to avoid potential denial of services
  • Retrieves appropriate clinical information from APeX as requested from county case workers for review as needed to secure approved SAR's, extensions, or modifications documenting all activity in APeX system.
  • The CCS Authorization Unit Representative is required to enter complete authorization information in the APeX referral activity screen documenting ongoing activity that may include all communication with patients, providers, CCS, or other departments until final determination is made on the authorization
  • Utilizes in depth job knowledge and expertise to address the patient, provider, CCS county and case manager questions regarding the authorization process
  • Meets the productivity and accuracy standards of overall Patient Access Services and units within the department. Actively participates in staff meetings to integrate changes in procedures, new program requirements or training reviews of existing procedures.   Updates and maintains own file of procedures, notices of changes, etc., so that related knowledge and skills are always current
  • Complies with Service Excellence and Patient Access department standards in interactions with patients, families, visitors and other staff. Maintains proficiency and complies with all applicable infection control, health and safety policies and procedures as implemented by the department and/or work unit and the Medical Center

Qualifications:

  • High school diploma or GED required
  • Three(3) years’ of clerical experience, including two (2) years at the Admitting Worker or comparable level
  • Proficiency in health insurance eligibility and authorization requirements
  • Knowledge of government program regulations, Medi-Cal, CCS, and third party payors’ patient liability determination
  • Ability to problem solve; ability to analyze data and recommend changes.
  • Demonstrated ability to utilize, understand and adapt to the use of electronic health record systems, billing systems, etc.
  • Attention to detail: understand cause and effect when accounts are not processed appropriately
  • Must have strong customer service skills to interact with medical providers, clinic and department staff and CCS county offices.   
  • Ability to work collaboratively with a culturally diverse staff and patient/family population.
  • Ability to work independently with minimum supervision.
  • Office Machine Skills:
  • ADT experience required, knowledge of office machines; typing 30 wpm. Must have basic PC skills.

$26 Per Hour          Emeryville, CA 94608         3 Month Assignment

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