Job Title: Patient Access Specialist

Job Code: PAS

Department: Patient Access

Division: Finance

Salary Level: Non-Exempt 4

Reports to: Patient Access Manager/Member Services Manager

Last Revised: May 2025

Primary Function

Greets all patients, families, visitors and coworkers in a prompt, polite, and helpful manner and directs them, as necessary. Determine, verify, and explain CIHA eligibility to patients, check-in or registering patients for their visits, and answering all incoming calls to the facility.

Answers the EBCI Tribal Option Member/Provider Services1800 number and effectively direct callers to the appropriate party, provide warm transfers when necessary and appropriate and provide external referral information to assist members/providers to get their needs met. Responsible for conducting patient interviews, distributing, and obtaining signatures for paperwork, entering pertinent information including demographic and insurance, verifying insurance eligibility, determining, verifying, and explaining services, and collecting co-pays if applicable. Receives complaint/grievance calls in a welcoming and supportive manner. Logs complaint/grievance information into the customer service platform and elevates complaint/grievance calls as appropriate to Tribal Option Management staff.

Job Duties

Patient Relations Duties

• Interviews patients to obtain pertinent patient registration information, i.e., demographic and insurance information and authorization to enable the Business Office to bill for health care services provided from all alternate resources, including the non-beneficiary service.
• Verifies all information collected for accuracy. Verifies insurance coverage through the health plan and determines applicable co-payment and collects co-payment if applicable.
• Creates and completes new charts in the BPRM Patient Registration System after researching and verifying that there is not an existing chart for the patient. This will include inpatient, outpatient, emergencies and after hour patients, dental patients, and mental health patients.
• Obtains and verifies the health records in the BPRM Patient Registration System for Medicaid, Medicare, and private/commercial insurance eligibility information for all patients seen prior to all clinic visits.
• Obtains signature for file on all required forms for alternate resource and contract health services prior to patients being seen in the clinics for billing purposes and/or contract health services eligibility.
• Makes corrections as necessary to improve the Patient Registration System. Updates PRC eligibility with proper documentation.
• Collects third party recipient health cards, obtains photocopies of the card and explains the program to the beneficiaries, i.e., why Medicare, Medicaid and/or Private Insurances will be billed for services they receive at the Cherokee Indian Hospital.
• Interviews patients to obtain information to initiate a new health record and/or communicate to Medical Records to reactivate a retire/stored record. Enters all information into the BPRM Patient Registration System and prints appropriate forms.
• Upon direction initiates all admitting forms to complete the admission with current patient data, including BPRM Patient Registration System. Initiates patient identification bands for admission.
• Completes Medicare Secondary Payer Questionnaire for Medicare beneficiaries and files appropriately.
• Transcribes all new insurance information into the BPRM system in all the appropriate fields. Verifies if patient has NC BCBS, NC Medicaid, or other private insurance.
• Calls pending verification patients before appointments to remind of documentation to bring in i.e., driver’s license, enrollment care, proofs of residency, etc.
• Obtains patient signature for Service Agreements, Notice of Privacy Practices, etc., scans forms signed by patients into VISTA.
• Documents MVA/WC in BPRM/RPMS by obtaining signatures for appropriate forms, giving clinic appropriate documents, obtaining police reports, entering appropriate benefit for coverage in order for the Business Office to bill correctly and alerts clinic staff.
• Documents all changes, updates on the notes page with date, and initials.
• Collects fees and co-pays from non-beneficiaries, prints register and credit card report at end of shift, maintains petty cash and turns all receipts and reports into Finance.

Member/Patient Service Duties

• Answers eligibility questions for new patients or Members and lets the individual know what the benefits are based upon eligibility status.
• Answers the Member/Provider 1800 Tribal Option line consistently and provides information, warm transfers, and referral information as appropriate and necessary to ensure caller’s needs are met. Member/Provider toll free number is to be answered during the CIHA Business Day defined as Monday-Friday 8:00-4:30, except for posted CIHA holidays.
• Follow approved Service Line scripts to ensure correct, consistent information is provided to the Member/Provider.
• Log every call received into the customer service platforms, CEEP and/or NCCARE360, to ensure appropriate documentation and resolution of all calls. This is the foundation of data that is required to be provided to the state as part of the PCCM Tribal Option Contract.
• Promptly returns calls to individuals or entities if a request for a call back is made after hours, the return phone call shall be made the following CIHA business Day during normal hours of operation. Triages the message and notifies applicable business owner based upon the type of information requested.
• Answer any inquires related to the Healthy Opportunities Pilot Program and direct calls to the appropriate staff member, department and/or outside entities.
• Answers telephone switchboard for all CIHA facilities and directs calls to appropriate staff member/department.
• Maintains an updated list of all departments, personnel, and extensions to assure proper transfer of calls.
• Greets visitors when necessary, answers questions, or directs them to the appropriate person or department.
• Maintains the vendor/visitor sign in and provides vendor/visitors with Visitor badge.
• Keeps a log of after hour call-in referrals and turns into PRC during regular business hours.
• Determines the need for interpreter or translation services and accesses the necessary platform(s) to ensure the individual receives communication in the manner necessary to provide effective communication with the individual. This includes but not limited to calls to/from Members with limited English Proficiency, as well as Members with communication impairments, including those with hearing, deaf-blind callers to include TTY, captioned phones, and amplified phones.

Documenting Member/Provider Grievances

• Document all Provider or Member grievances/complaints received via the service lines or in person.
• Provide complete and appropriate documentation of all complaints/grievances within the customer service platform.
• Elevate complaint/grievances to the appropriate Tribal Option Manager per policy/protocol.

Other Duties as Assigned

• Performs other duties as requested from the Patient Registration Manager, or Member Services Manager

Education/Experience/Minimum Qualifications

• High school diploma/GED is required.
• An Associate’s Degree in Business and/or Accounting, or a related field, or the equivalent combination of training, education, and experience is preferred.
• Previous data entry experience or clerical experience with customer contact of two years is required.
• Three to six months in the job would be necessary to become proficient in most phases of the work.

Job Knowledge

• Ability to establish and maintain effective working relationships with members of the CIHA team, individuals and their families, and a variety of governmental and private resources and organizations in the community.
• Ability to express ideas clearly and concisely and to plan and execute work effectively.
• Must be able to read, research, and interpret computer data or customer service platform related to patient/member interviews and eligibility searches. Basic knowledge of eligibility requirements of the Cherokee Indian Hospital and the EBCI Tribal Option including resources in the local community and neighboring counties.
• Requires the ability to answer and transfer calls using the phone system and utilize computer, calculator, and related office equipment.
• Requires knowledge of various software packages: i.e. Microsoft Excel, Word, Outlook, and the Customer Service Platform and ability to enter information or data into the applicable software package. Documentation must be in “real time”.
• Knowledge of interview techniques and experience in applying various policies and procedures in the performance of assigned duties. Must be able to maintain specified records, files, and logs of the department.
• Must have excellent communication skills, both written and verbal.
• Requires the ability to work independently or as a member of a team. Valid NCDL required. Knowledge and ability to work within multiple systems simultaneously.
• Knowledge of complaint/grievance workflows call transfer matrix as well as Tribal Option information and how to locate Tribal Option information to assist Members/Providers.
• Knowledge of the population served and about the Cherokee culture preferred.

Complexity of Duties

This position is responsible for assisting individuals connect to the right service or entity within CIHA/EBCI Tribal Option or the ability to refer to applicable entity based upon eligibility criteria. As such, the position requires the ability to listen and filter relevant information in order to refer accordingly without causing confusion or disruption to the communication event. Duties require the application of judgment and problem-solving skills in order to be effective. At times may be dealing with individuals who are concerned about access to services, dissatisfied, agitated or emotional.

• The position requires ability to operate multiple software packages, documenting information in the appropriate software platform. In addition, the position must possess phone skills, including familiarity with complex or multi-line phone systems.

Responsibility for Accuracy

Typically, this position is the initial point of contact patients checking in for services rendered at CIHA and also for calls received via the EBCI Tribal Option Member/Provider Service Line. As such, accuracy is of upmost importance to ensure that eligibility data is accurate and information shared is accurate. Responsible for accuracy of demographic, eligibility and insurance information obtained and entered into BPRM/RPMS. Errors can be detected through interview techniques and subsequent interviews with patients or Members. Work can be verified or checked by the immediate supervisor, or other hospital staff. Incoming or outgoing calls can be monitored to ensure accuracy and adherence to approved scripts. Logged calls and complaints/grievances must be accurate and meet state reporting requirements.

NC Medicaid requires that calls from Members and Providers be answered in a certain manner, adhering to approved scripts. In addition, documentation must be gathered in real time, addressing all required fields so that reporting may be conducted and submitted in accordance to the DHHS Tribal Option Contract. NC Medicaid or other regulatory agencies may conduct “mystery shopping”, audits or reviews to ensure compliance to EBCI Tribal Option requirements.

Contact with Others

This position has primary contact with patients/members and providers for the purpose of conducting interviews, answering the Tribal Option Member/Provider line, accepting and documenting grievances/complaints and the patient/member registration process. Secondary contacts include, but not limited to staff within CIHA such as medical records staff, pharmacy staff, billing office staff, and contract health staff and other external entities visiting CIHA or calling in.

All contacts require tact, courtesy, and professional decorum. Utmost sensitivity and confidentiality is required when dealing with patients and families. Consistently demonstrates superior customer service to patients/members, providers, and customers. Ensures excellent customer service is provided to all patients/members, providers, and customers by seeking out opportunities to be of service.

Confidential Data

All health information and data is considered highly confidential and strict adherence to all applicable policies is required. The position has access to highly confidential patient/member medical and personal information. The Privacy Act of 1974 mandates that the incumbent shall maintain complete confidentiality of all administrative, medical, and all other pertinent information that comes to his/her attention or knowledge. The Act carries both civil and criminal penalties for unlawful disclosure of records. Violations of such confidentiality shall be cause for adverse action. The individual must always adhere to all CIHA/EBCI Tribal Option confidentiality and security policies and procedures.

Mental/Visual/Physical

The level of concentration varies with tasks, with close attention to detail required while entering data and verifying accuracy of information. Duties of this position require the employee to be mobile, reach with hands and arms, speak, and hear. Must have visual acuity. Position is subject to frequent interruptions, requiring varied responses. Must be able to handle multiple projects simultaneously, work independently, and meet deadlines and time frames. May occasionally move more than 15 pounds.

Resourcefulness and Initiative

Follows well defined procedures with initiative and judgment required maintaining accuracy and complete tasks in a timely fashion.

Environment

Majority of work is performed within the hospital environment requiring interaction throughout the hospital. Occasional travel is required. Immunizations are required of all employees.

Customer Service

Consistently demonstrates superior customer service skills to patients/customers by demonstrating characteristics that align with CIHA’s guiding principles and core values. Ensure excellent customer service is provided to all patients/customers by seeking out opportunities to be of service.