Pre-Certification Specialist

CAMC Health System•Charleston, WV

About The Position

The Pre-Certification Specialist obtains accurate pre-certification authorizations and referrals for new and returning patients, reviews and completes patient charts, and schedules physician-ordered tests, exams, procedures, and surgeries as applicable. The role reviews patient insurance information and works with Medicare and other insurance companies to establish requirements, obtain necessary information, and facilitate authorizations and referrals. It also performs related clerical, account setup, scheduling, and payment duties, while maintaining knowledge of treatment trends, medical terminology, and coding systems. The specialist cross-trains for front desk and medical assistant roles and provides backup as needed. The employee must demonstrate the knowledge and skills necessary for developmentally appropriate assessment, treatment, or care for the patient ages identified by the department, including interpreting information in terms of patient needs, knowledge of growth and development, and understanding the range of treatment needed. Competency is established through initial orientation and ongoing validation to independently perform assigned tasks and duties. The role also requires maintaining applicable education records, providing positive customer service and coworker relations, complying with attendance and departmental policies, participating in quality improvement, working cost-effectively, and supporting the organization’s mission and strategic plan. Related duties may be assigned.

Requirements

High school diploma or GED.
No certification, competency, or license is required.
Demonstrate competency through initial orientation and ongoing competency validation to independently perform assigned tasks and duties.
For positions with direct patient contact, possess or obtain by the end of orientation and demonstrate the knowledge and skills needed for developmentally appropriate patient care, including interpreting patient information and needs, knowledge of growth and development, and understanding the range of treatment needed.

Responsibilities

Review charts daily to determine whether pre-certification, pre-authorization, or referrals are required.
Review patient insurance information to determine medical-necessity requirements for specific treatments.
Communicate with Medicare and insurance companies to obtain information on compliance, authorizations, verifications, progress notes, medical-necessity guidelines, and pre-certification and pre-authorization requirements.
Perform clerical duties, including composing letters to patients, insurance carriers, and referring physicians regarding issues.
Schedule patient surgeries per physician orders and communicate necessary information to appropriate parties.
Make subsequent referrals to other physicians based on physician review of test or scan results.
Establish new patient accounts in billing software upon receiving physician referrals and forward applicable information to appropriate personnel for the medical chart.
Maintain knowledge of treatment trends, current medical terminology used in pre-certification, and ICD-10, CPT, and HCPCS codes.
Cross-train for front desk and medical assistant roles and provide backup as needed.
Schedule procedures and collect, apply, and deposit funds.
Maintain and document required education.
Demonstrate positive customer service and coworker relations.
Comply with the company’s attendance policy and departmental pay practices and scheduling policies, including overtime, shift work, and on-call situations.
Participate in departmental and institutional continuous quality-improvement activities and perform work cost-effectively.
Perform work in alignment with the organization’s mission, strategic plan, and applicable policies and procedures.
Perform related duties as assigned.