The Patient Access Specialist facilitates patient access to hospital services and affiliated service areas. Responsibilities include processing patient registration information with a high degree of accuracy, collecting patient demographic and third-party payer data, and performing financial collections. This role ensures the timely preparation and presentation of legal, ethical, and compliance-related documents to patients during registration, providing thorough explanations as required.

The specialist maintains current knowledge of JCAHO standards, Patient Rights and Responsibilities, HIPAA regulations, HMOs, commercial payers, and departmental policies and procedures. Additional duties include scheduling mammography screenings and serving as a liaison between ancillary departments and other Patient Access Services areas. Work may occur in patient care settings.

Education:

High School diploma required. 

Licensure/Certification/Registry:

Must successfully complete assigned annual education through Healthcare Business Insights.

Experience:

One (1) years of business office experience, preferably in the areas of Patient Access, billing, collections, insurance principles/practices, or accounts receivable. Completion of 12 (twelve) hours of coursework in a business or healthcare related field of study may be considered in lieu of business office experience. Previous experience in Patient Access is highly desirable.  

Other Knowledge/Skills/Abilities:

• Knowledge of all tasks performed in the various Patient Access Service areas is necessary to provide optimum internal and external customer satisfaction and provide the opportunity for accurate reimbursement. 
• Demonstrates superior patient relations and interpersonal skills; demonstrates an appropriate level of mental and emotional tolerance and even temperament when dealing with staff, patients and general public, using tact, sensitivity and sound judgment; promotes a positive work environment and contributes to the overall team efforts of the department and organization.
• Working knowledge of computers is required, with the ability to enter and retrieve data, and electronically notate registration software, and other required applications/systems.
• Must demonstrate detail orientation, critical thinking, and problem solving ability.
• Must demonstrate excellent oral and written communication and customer service skills, with ability to maintain a calm and professional demeanor in high stress situations.
• Demonstrated ability to remain flexible, and consistently exercise sound judgment and initiative in very stressful situations.
• Ability to effectively manage competing priorities and work independently in a rapidly changing environment.
• Must demonstrate ability to educate, persuade, and negotiate effectively with patients and families.
• Knowledge of medical terminology, medical procedural (CPT) and diagnosis (ICD 10 CM) coding, and hospital billing claims preferred, but not required.

• Completes all steps of pre-registration/registration; verifies patient identity and demographic information through appropriate tools. Identifies/captures appropriate health insurance benefit eligibility based on contract/regulatory differentiation. Facilitates appropriate billing of claims and hospital reimbursement. Obtains and validates proper consent for patient treatment.
• Schedules patients for Mammography procedures efficiently, effectively, and according to established protocol for modality, location, facility capabilities, insurance requirements, type of exam, patient preferences, and urgency.
• Educates patients/others regarding the resolution of billing, private pay options, collection efforts, coordination of benefits, third party and governmental payment criteria, insurance coverage, payments, and denials. May serve as a liaison between external resources and patients on issues requiring SMH involvement.
• Coordinates with SMH Patient Financial Services, Utilization Management, physicians, and medical offices to ensure consistent financial documentation across the enterprise, and an interdisciplinary approach to patient and organizational needs.
• Adheres to all CMS Conditions of Participation regulations and Section 1154(e) of the Social Security Act regarding delivery, explanation, and acquisition of patient/designated representative signatures.
• Verifies medical necessity, and obtains appropriate signature on Advance Beneficiary Notice of non-coverage (ABN) per CMS regulations at points of patient access.
• Negotiates with patients and families to collect patient co-pays and/or deposits at point of service. Supports Patient Access Services POS (Point of Service) collection goals as defined by Revenue Cycle leadership and best practice benchmarks.
• Triages, documents, and initiates referrals of patients to Medicaid vendor and/or for financial assistance, per the Illinois Fair Patient Billing Act, Illinois Uninsured Patient Discount Act, and established SMH procedures.
• Identifies/reviews services requiring pre-authorization/pre-certification by Medicare, Medicaid, Commercial, and Managed Care payers, to ensure provider eligibility requirements are met prior to receiving service. Utilizes appropriate technology and/or communicates with physician offices.
• Analyzes reports containing rejected accounts from a variety of hospital sources, including Non-Patient Access registration departments, and resolves toward verification of patient benefit eligibility, and subsequent reimbursement from all possible payer sources, or determines suitability for financial assistance.
• Orients and cross-trains others within assigned area of responsibility as directed and defined by management. May assist other areas within the unit or department, as necessary, during times of special needs or staff absences. May be required to work night or weekend shifts.
• Ensures compliance with all applicable HIPAA, Joint Commission, CDC, SMH, and state and federal statues, providing required associated literature to patients at all PAS access points. Educates patients regarding Advance Directives, Medicare D prescription coverage, SMH, Joint Commission, and Illinois Department of Public Health grievance process as appropriate.
• Maintains current knowledge of, and complies with, the Illinois Fair Patient Billing Act and Illinois Uninsured Patient Discount Act at all times.
• Completes Illinois DHS legal forms for psychiatric admits, in compliance with State of Illinois and SMH statues and guidelines. Provides relevant patient/family education.
• May rotate work settings, i.e., patient registration, bedside registration, or other SMH campus environments. May be required to provide coverage for the SMH Financial Lobby Office.
• Develops and maintains a comprehensive knowledge of the health system organization and its functions. Completes all assigned annual organizational education
• Meets expectations for productivity, accuracy, and point of service collections
• Attendance at quarterly department meetings is mandatory unless absence is approved by PAS management prior to the meeting date.
• Performs pre-registration functions as requested.
• Performs other related work as required or requested.