Pre-Certification Nurse Coordinator

Children's Hospital of Philadelphia

1d•Hybrid

About The Position

The Financial Clearance team is seeking a highly skilled Precertification Nurse Coordinator to support complex clinical authorization requirements by applying nursing expertise to secure timely payer approvals, ensure medical necessity compliance, and minimize authorization-related denials for scheduled services. The Precertification Nurse Coordinator is responsible for collecting the required medical data and insurance information necessary for the precertification of elective inpatient and outpatient admissions and selected OP procedures. The Precertification Nurse Coordinator acts as a resource to the Authorization Specialist in the Precertification Department. Flexible Work Location & Team Connection The primary work location for this role is home/remote. The position balances flexible work arrangements with a collaborative team environment and requires quarterly onsite meetings at the Main CHOP Hospital.

Requirements

Technical Diploma Nursing Required
At least two (2) years experience in an acute pediatric hospital setting. Required
Registered Nurse (Pennsylvania) - Pennsylvania State Licensing Board - upon hire - Required
Ability to exercise judgment and react resourcefully under varying conditions
Excellent communication skills and demonstrated organizational skills
Must demonstrate professionalism to all internal and external customers
Ability to complete multiple tasks and meet deadlines
Ability to maintain confidentiality of patient information
Computer literate
Must be customer service oriented
ICD 9 and CPT coding

Nice To Haves

Bachelor's Degree Nursing Preferred
At least one (1) year utilization and/or precertification experience Preferred

Responsibilities

Reviews incoming Precert requests for completeness in EPIC.
Evaluates and ensures diagnosis and procedures are classified correctly for place of service: inpatient versus outpatient.
Ensures diagnosis and procedure coding accurately reflects clinical information and procedures to be performed.
Contacts physician offices to obtain detailed medical information as needed after review of Precert requests prior to calling third party payers (TPPs.)
Update insurance info as needed in EPIC.
Create HAR as needed in EPIC.
Accurately documents pre-cert info in EPIC.
Demonstrates proficiency in disease physiology and keeps current with changes as they relate to procedures and treatments.
Discuss disease physiology, past medical history and other pertinent health information in order to facilitate approval of admission.
Consults Research/physician office/clinic in order to ensure accuracy of treatments/procedures before contacting TPP.
Collaborates with internal departments to ensure precertification is obtained in a timely and efficient manner.
Obtains precertification for Cardiac, Hematology, Oncology, Critical Care, Endocrinology, Metabolism, Neurology, Rheumatology and other areas as assigned.
Forwards non-par cases to be negotiated to the Manager of Special Care programs.
Ensures agreements have been negotiated prior to admission or service performed.
Facilitates and obtains precertification prior to elective transfer from other acute care facilities.
Precertifies critical care vent dependent patients for the Progressive Care Unit (PCU.)
Adheres consistently to changing third party payer criteria as it pertains to the hospital financial policy to ensure revenue capture.
Obtains precertification according to TPP policy; meets requests for additional information in a timely manner.
Coordinates the communication between physician offices and third party payers concerning contract exclusion and/or denials.
Denials are handled as per policy including follow up with the physician office regarding the denial.
Provides information regarding exceptions form.
Informs physician of correct procedure to follow when notification of TPP contract exclusion or denial of requested services is received.
Refers self-pay patients to business office for payment options.
Interfaces with Case Management, Business Office and Bed Management to help maximize reimbursement.
Researches and shares pertinent data with other departments, as necessary.
Functions independently and able to direct others in order to facilitate the smooth operation of the Precert Department.
Assists PSA staff in interpreting clinical information, diagnoses and/or procedures.
In the supervisor’s absence, prioritizes workload and delegates responsibilities to other staff members.
Liaison with physician offices, as necessary in supervisor’s absence.