Pre-Certification Specialist

CAMC Health System•Charleston, WV

1d•Onsite

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 insurance information and works with Medicare and insurance companies to confirm requirements, medical necessity, authorizations, verifications, and supporting documentation. It also performs related clerical and patient-account duties, coordinates referrals, and provides backup support for front desk and medical assistant roles. The employee must complete initial orientation and ongoing competency validation to perform the assigned tasks independently. For positions involving direct patient contact, the employee must demonstrate appropriate patient-group knowledge and skills by the end of the orientation period. The position also requires maintaining applicable education, providing positive customer service, following attendance and organizational policies, participating in quality improvement, and working in accordance with departmental scheduling and pay practices.

Requirements

High school diploma or GED.
No certification, competency, or license is required.
Complete initial orientation and ongoing competency validation to independently perform assigned tasks and duties.
For positions with direct patient contact, demonstrate 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.
Maintain and document applicable required education.

Responsibilities

Review patient charts daily to determine whether pre-certification, pre-authorization, or referrals are required.
Review patient insurance information to identify 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 pre-certification 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 based on physician review of test or scan results.
Create new patient accounts in billing software upon receipt of physician referrals and forward applicable information for inclusion in medical charts.
Maintain continuing education regarding 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 co-worker relations.
Comply with the company's attendance policy and applicable departmental pay practices and scheduling policies, including overtime, shift work, and on-call situations.
Participate in departmental and institutional continuous quality improvement activities.
Perform work cost-effectively and in alignment with the organization's mission, strategic plan, policies, and procedures.
Perform related duties as assigned.