Pre-Certification Specialist (Full-Time)

Billings Clinic•Billings, MT

9d•Onsite

About The Position

The Pre-Certification Specialist is responsible for completing pre-certification, prior authorization, and notification requirements for third-party and government payers for pre-scheduled elective inpatient and outpatient examinations and procedures that require preauthorization. The specialist may provide backup pre-certification and prior-authorization support to other departments and coordinates with physicians, nursing staff, and other healthcare providers on process requirements. The position tracks, documents, and monitors authorizations; helps ensure compliance through checks and balances; and works with providers, patients, payers, Medical Staff, Payer Relations, and Patient Financial Services to resolve authorization issues and coordinate approvals for in-network services. The specialist also maintains payer reference materials and data, supports patients and families with authorization status information, and keeps current with relevant process developments and safety requirements.

Requirements

High school graduate or equivalent.
One year of medical insurance claims experience through patient accounts billing or claims adjudication.

Responsibilities

Support and practice the mission and philosophy of Billings Clinic and the Radiology Department.
Coordinate the pre-certification process with provider offices, targeting preauthorization of 98% of prescheduled elective inpatient and outpatient procedures.
Document and maintain patient-specific pre-certification and authorization data in required information systems; compile, document, and track monthly pre-certifications using established procedures.
Keep an updated list and ensure correct patient status when completing pre-certification.
Review CPT-4 codes requiring pre-certification or authorization and ensure the Passport pre-certification process is met.
Report denials and delays to physicians, other healthcare providers, and patients; provide patients with information about appropriate appeal procedures when applicable.
Investigate and research pre-certification problems and coordinate their resolution.
Report non-compliance issues and program expansion needs to the Manager.
Work with Medical Staff, Payer Relations, and Patient Financial Services to coordinate required authorizations for in-network services.
Track and verify receipt of authorizations, whether verbal or written, and communicate status to providers and patients as needed.
Develop and maintain collaborative working relationships with payers and healthcare providers.
Review, update, and standardize forms and processes as needed.
Participate in interdepartmental meetings to coordinate work, resolve process issues, and foster communication.
Develop and maintain reference manuals describing individual payer requirements for pre-certification and prior authorization; ensure payer data integrity and accuracy.
Assist patients and family members with pre-certification or re-certification status information.
Identify personal growth and development needs, meet mandatory system and department requirements, and maintain knowledge of current trends and developments in pre-certification.
Maintain competency in applicable organizational, departmental, and outside-agency environmental, employee, and patient safety standards.
Perform other duties as assigned or needed to meet department or organizational needs.