Pre-Certification Representative II

Nevada System of Higher Education•Arlington Heights, IL

50d•$21 - $30

About The Position

Under the management of the Manager, Patient Access, the Pre-Certification Representative II is responsible to initiate and manage referrals / pre-authorization / pre-certification based on clinical orders for an assigned patient population. In addition the Pre-Certification Representative II is responsible to determine insurance eligibility and, as appropriate benefits and medical necessity requirements based on patient specific insurance. The Pre-Certification Representative II provides these services to ensure that our customers are provided a high quality experience which includes understanding of patient responsibility and ease of access to clinical services. This is achieved through coordination with and education of the patient. The Pre-Certification Representative II helps to insure that patient satisfaction and loyalty are achieved while hospital and Medical Group revenue is optimized.

Requirements

High School Diploma
1 year of related insurance experience required.
Registration and billing experience preferred.
Experience with referral and pre-certification initiation, processing and coordination strongly preferred.

Responsibilities

Submits referral and / or pre-certification requests for physician visits, diagnostic testing, procedures, durable medical equipment, home care and all other medical care services, per individual carrier procedures.
Communicates and coordinates with office or physician if payer specific additional clinical information of physician peer to peer is necessary to successfully process the referral or pre-certification.
Communicates negative payer determinations (denied authorizations) to ordering physician / department to facilitate decision making in clinical next steps.
Communicates third party payer decision on authorization / pre-certification to patient. This includes communication and education of patient regarding patient specific insurance carrier requirements and possible out of pocket patient responsibility.
Documents outcomes and statuses related to all referral and pre-certification requests in Epic. This includes approvals, denials, status, outcomes, etc.
Consistently follows prescribed workflows, standards and protocols for managing and obtaining referrals, authorizations and priorities.