Pre-Certification Specialist

The Pre Service areas of technical competencies should include: Advanced knowledge of office equipment, computers, and insurance websites. Advanced knowledge of all healthcare insurance payers and authorization guidelines. Ability to communicate clinical documentation and insurance protocols for authorization. Create a positive impression for each patient, family member, visitor or staff while performing the tasks of scheduling and pre-certification. Schedule and obtain insurance pre-certification/pre-determination, and evaluate medical necessity compliance prior to patients receiving medical services, ensuring accuracy and timeliness. Obtain demographic information and validate insurance. Answer and provide resolution for any questions received from patients, visitors, and staff. Within scope of job, requires critical thinking skills, decisive judgment, effective oral and written communication skills, and the ability to work with minimal supervision. Must be able to work in a fast paced environment and take appropriate action.

Job Duties/Expectations:

• Ensure departmental compliance auditing physician orders compared to actual scheduled procedure for accuracy. Upon receiving the written or electronic order, verifies completeness including accurate patient status, CPT code and ICD 10. Follow up with ordering physician to obtain correct orders and clinical information that supports medical necessity prior to services being rendered.
• Verifies patient insurances via insurance verification system, websites or by phone 100%. Communicate and support hospital departments using appropriate systems
• Responsible for the timely pre-certification, authorization, and verification of insurance coverage working a minimum of 3 days out. Demonstrates the ability to obtain certifications within the payer's timeframe. Complete worklist daily working 2- 3 days out 100% of the time. Work to meet the demands/protocol of Hold & Calls in a timely manner.
• Validate pre-cert/pre-auth information after receiving final determination 1-3 days prior to date of service. Complete medical necessity and/or pre-determination requirements when applicable.
• Meets department goal of data accuracy using the appropriate insurance authorization website or by phone 100% of the time.
• Documents critical authorization information to ensure claims payment. Ensure departmental compliance of staff entering correct data into the appropriate systems for standard work flow documentation.
• Organize and monitor work flow to deliver a positive patient experience in all encounters. Resolves patient issues in a concise and informative manner notifying MD and patient of authorization denial or downgrade of test.
• Will serve as a mentor assigned in this role to foster Professional Development, training and continuous cycles of improvement for the organization. Mentoring will begin with induction to the role and endure throughout the tenure of each employee assigned to the department. Within scope of job requirements must possess critical thinking skills, decisive judgment and the ability to work with no supervision.
• Makes process improvements or initiates courses of action for problem resolution. Participate in continuous process improvement activities utilizing LEAN concepts to meet goals. Assist in research and follow-up for denials and in creating a plan to prevent future denials.
• Accepts work assignments willingly, with positive attitude and learns new job assignments in a reasonable period of time. Strong work ethic and energy. Focuses on personal development. Builds and maintains collaborative relationships with both internal and external Clients that lead to more effective communication and a higher level of productivity and accuracy.

Job Duties:

• Responsible for the timely pre-certification, authorization, and verification of insurance coverage
• Ability to work and support across multiple departments within Maury for pre-cert duties
• Training can be a long process: Candidates will be given all the basics of their duties within the first 2-3 weeks, but they will continue to learn as they go for the entire 5 months.

• Tight-knit team
• Ability to work in-between contract jobs

• Experience with Cerner (or similar) EMR platforms
• 1-2 yrs of Medical/Physicians Front Desk Office or CBO hospital setting or billing (1-2 yrs of medical billing would also be translatable)
• Tenured exp and knowledge of pre-certification, authorization, and verification of insurance processes

• Scheduling experience
• Pre-certification experience