Pre-Certification Specialist

CAMC Health System • Charleston, WV

1d

About The Position

The Pre-Certification Specialist obtains accurate pre-certification, pre-authorization, and referrals for new and returning patients, reviews and completes patient charts, and schedules physician-ordered tests, exams, procedures, and surgeries. The role reviews insurance requirements and medical necessity, coordinates with Medicare and insurance companies, and communicates relevant information to patients, insurers, referring physicians, and other appropriate parties. The specialist also establishes patient accounts, supports referrals, maintains knowledge of current medical terminology and coding, and cross-trains to provide backup for front desk and medical assistant roles.

The employee must demonstrate competency through initial orientation and ongoing validation, including the patient-care knowledge and skills required for any direct patient contact. Common duties include maintaining required education, providing positive customer service, following attendance and scheduling policies, participating in quality improvement, working cost-effectively, and complying with organizational policies and the organization’s mission.

Requirements

• High school diploma or GED.
• Demonstrate the knowledge and skills necessary for developmentally appropriate assessment, treatment, or care for the patient ages identified by the department, if the role involves 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.
• Demonstrate competency through initial orientation and ongoing competency validation to independently perform assigned tasks and duties.

Responsibilities

• Review charts daily to determine whether pre-certification, pre-authorization, or referrals are needed.
• Review patient insurance information to determine medical necessity requirements for treatments.
• Coordinate with Medicare and insurance companies to obtain information on 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 based on physician review of test and scan results.
• Establish new patient accounts in billing software after receiving physician referrals and forward applicable information for inclusion in the medical chart.
• Maintain continuing education on 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, provide positive customer service, comply with attendance and scheduling policies, participate in continuous quality improvement, perform work cost-effectively, follow organizational policies, and perform related duties as assigned.

What This Job Offers

• Job Type: Full-time
• Education Level: High school or GED