Pre-Certification/Authorization Coordinator - Remote

Tufts Medicine

19h•Remote

About The Position

This role focuses on activities related to revenue cycle operations including, but not limited to billing, collections, cost estimates and payment processing. Additionally, it involves performing Patient Access duties such as administrative and financial-clearance tasks to facilitate clinical services. Responsibilities include collecting patient demographic and financial information, scheduling services, and managing referrals from primary care doctors for appointments and procedures. This is an organizational support or service role, administrative or clerical in nature, focusing on daily business activities in a "hands on" environment. Most time is spent delivering support services under supervision. It is an entry-level role typically requiring little to no prior knowledge or experience, with routine work following standard procedures, closely supervised, and involving communication that requires minimal explanation or interpretation.

Requirements

High school diploma or equivalent
Two (2) years of related experience in a hospital, physician office, or financial services
Knowledge of medical terminology.
Knowledge of ICD-10 and CPT coding.
Thorough working knowledge of insurance, payer precertification requirements for in-network, out-of-network, Medicare, and Medicaid.
Knowledge and willingness to learn computer systems (Microsoft Word/Excel).
Strong verbal and written communication skills. Must demonstrate a patient service focus.
Excellent organizational skills, ability to prioritize work assignments, and attention to detail.
Ability to respond effectively to changing priorities and work processes.
Ability to work independently and participate in teams within the department and hospital.
Strong customer services skills including excellent interpersonal and telephone skills.
High degree of tact is necessary due to frequent interaction with patients, physicians, and insurance companies.
Knowledge and understanding of health care delivery systems with special emphasis on the referral management process for managed care providers.

Nice To Haves

Associate’s degree
Five (5) years of related experience in a hospital, physician office, or financial services

Responsibilities

Contacts insurance companies, and workers compensation carriers to obtain verification of insurance, eligibility, and level of benefits. Enters benefit information into hospital electronic medical record system.
Contacts patients, when necessary, for updates of financial and demographic information. Ensures timely updates in EMR.
Obtains financial data from a variety of sources including both in-state and out-of-state payers. Utilizes computer systems, payer eligibility sites & phone outreach.
Arranges for coordination of benefits when more than one insurance carrier is involved.
Seeks administrative approval of admission (precertification) for surgeries, admissions, procedures, imaging, outpatient specialty referrals, home health, hospice and all other in-scope services by providing clinical data to payers and obtaining PCP Insurance referrals and/or authorization. Enters precertification and referral information and proper documentation into the hospital EMR.
Identifies procedures & services that are not covered services by individual insurance policies.
Communicates all identified financial risk concerns to the ordering department and Patient Access leadership for immediate review and resolution.
Collaborates with Financial Coordination and Pre-Registration colleagues regarding patients with identified financial risk concerns for resolution prior to services being rendered.
Obtains all applicable clinical documentation when required by insurance payers for elective services and submits information to payers within a timely and secured manner.
Closely follows case statuses and communicates and/or documents in hospital system, pending and approved statuses within a timely manner.
Immediately identifies denied claims and works closely with department leaders, coordinators and clinical team members toward their appeal and peer to peer workflow.
Monitors productivity and quality of workflow directly, reaching days out, productivity, and quality review goals.
Acts as a resource to other departments of the hospital regarding precertification policies and resolution of accounts including providing documentation records to assist with insurance appeals if a denial is received.
Maintains collaborative, team relationships with peers and colleagues to effectively contribute to the working group’s achievement of goals, and to help foster a positive work environment.
Works closely with Case Management and Admitting colleagues to confirm level of care changes, particularly for unplanned or urgent admissions, and communicates level of care upgrades or downgrades with payers within a timely manner.
Learns and adapts new workflow changes and updates as they occur in real-time and maintains an openness to updated workflows.
Assists in the training and shadowing of new team members.