Pre-Certification Specialist
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, examinations, procedures, and surgeries. The role reviews patient insurance information and medical necessity requirements, coordinates with Medicare and insurance companies, and communicates with patients, referring physicians, and other appropriate parties. The specialist also establishes patient accounts in billing software, forwards information for inclusion in medical charts, maintains knowledge of treatment trends and relevant medical terminology and coding, and cross-trains to provide backup for front desk and medical assistant roles. The employee must demonstrate the patient-group knowledge and competencies required for the department, including the ability to obtain and interpret information in terms of patient needs, knowledge of growth and development, and understanding of the range of treatment needed by patients. Competency is established during orientation and validated on an ongoing basis. The position also includes general organizational duties such as maintaining required education records, providing positive customer service, following attendance and departmental policies, participating in quality improvement, working cost-effectively, and performing related duties as assigned. The role is full-time, regular, with a 1.0 status, and has a day schedule at Memorial-MSOB in Charleston, West Virginia.
Requirements
- High school diploma or GED.
- Demonstrate required patient-group knowledge and skills by the end of the orientation period, including the ability to obtain and interpret information in terms of patient needs, knowledge of growth and development, and understanding of the range of treatment needed by patients.
- Demonstrate competency through initial orientation and ongoing competency validation to independently perform assigned tasks and duties.
- No certification, competency, or license is required.
Responsibilities
- Review patient charts daily to determine whether pre-certification, pre-authorization, or referrals are needed.
- Review patient insurance information to determine medical necessity requirements for specific treatments.
- Communicate with Medicare and insurance companies to obtain information about compliance, authorizations, verifications, progress notes, medical necessity guidelines, and precertification and pre-authorization requirements.
- Perform clerical duties, including composing letters to patients, insurance carriers, and referring physicians about relevant issues.
- Schedule patient surgeries according to physician orders and communicate necessary information to appropriate parties.
- Make subsequent referrals to other physicians following physician review of test or scan results.
- Establish new patient accounts in billing software after receiving a physician referral and forward applicable information for inclusion in the medical chart.
- Maintain knowledge of treatment trends, 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.
- Participate in departmental and institutional continuous quality improvement activities.
- Perform work cost-effectively and in accordance with departmental pay practices and scheduling policies, including overtime, shift work, and on-call situations.
- Follow organizational and departmental policies and procedures and perform related duties as assigned.
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What This Job Offers
Job Type
Full-time
Education Level
High school or GED
