Precertification Specialist - Mon - Fri 9 AM - 5:30 PM

Under the supervision of the Utilization Review Manager, this position is responsible for ensuring the delivery of outstanding customer service in the process of obtaining pre-certification approvals from insurance companies (for both inpatients and outpatients), identifying insurance and/or patient responsibility, insurance verification, admission notifications, identifying approved days, follow up required, and providing financial counseling when appropriate.

Responsibilities

Ensure all scheduled and non-scheduled inpatient and outpatient accounts are pre-authorized either in advance or on the day of the notification of admission; Provide and interpret clinical information submitted from the Physician, emphasizing the medical justification for a procedure; Work with Physician offices, Case Management, Utilization Review, and patients to obtain supporting clinical data for the payer; Obtain complete and accurate insurance information and complete verification of patient eligibility for inpatient and outpatient hospital visits; Act as liaison and point of contact between clinical staff, ancillary departments, patients, referring Physician offices, and insurance payers to inform of authorization delays/denials; Collaborate with Utilization Review nurses to ensure authorization for services is obtained and fully documented; Ensure thorough documentation of verification and authorization activities in the patient account; Communicate with Physician offices and payers to initiate and mediate Physician to Physician reviews; Understand and retain knowledge of payer requirements in relation to procedure vs. plan type and determine when a pre-authorization is needed; Accurately and timely document the pre-certification in the appropriate account; Collaborate with the appeals department to provide information to overturn denied claims; Help monitor insurance authorization issues to identify trends and participate in process improvement initiatives; Answer, manage, and satisfy customers during all incoming calls and meet department goals relating to outbound calls, average speed to answer, max delays, AUX times, abandonment rate, and ACD time; Meet NGHS STARS customer service standards; Meet department goals including productivity, accuracy, collections, and customer satisfaction; Perform related job duties as assigned

Requirements

High School Diploma or GED; Ability to work independently, emotionally mature, and able to function effectively under stress; Excellent problem solving and analytical skills; Excellent written and oral communication skills; Ability to prioritize, organize, and coordinate daily work load; Working knowledge of Protected Health Information; Ability to manage change; Extensive knowledge of medical terminology; Detailed understanding and knowledge of insurance guidelines and protocols, the components of full verification, and payer information / requirements

Nice to have

AAPC, AHIMA or CPC certification strongly preferred; 3–5 years of relevant experience in insurance authorization, precertification, medical billing, revenue cycle, patient access, or related healthcare operations strongly preferred