Precertification Specialist 1

Mercyhealth Wisconsin and Illinois•Janesville, WI

1d•$18 - $26

About The Position

The Precertification Specialist 1 is responsible for identifying scheduled patients requiring pre-certification or pre-determination, gathering necessary patient data, and contacting insurance companies or employer groups to obtain these authorizations. This role involves determining eligibility and benefits, following up on insurance issues for financial resolution, and obtaining clinical documentation for the pre-certification process. The specialist coordinates follow-up to ensure procedures are authorized and documented prior to the date of service, meeting all payor requirements for payment. They communicate outcomes, benefits, and patient financial responsibilities to Mercy Partners and Patient Financial Counselors. The role requires maintaining current knowledge of payor provisions, regulations, ICD-9/ICD-10 and CPT coding, and utilizing computer software for pre-certification. The specialist must meet department productivity and accuracy expectations, adhere to patient confidentiality policies, and determine network status, eligibility, and coverage. Professional communication with provider offices for peer-to-peer information is essential for obtaining authorizations for procedures pended for medical review. Documentation standards must be followed on all patient encounters, ensuring account status is accurately reflected. The ability to work independently with minimal supervision and be result-oriented is crucial. Training and mentoring may be provided. This position may require working alternate shifts, weekends, and overtime during peak periods, and participation in educational programs for mandatory requirements and personal growth.

Requirements

High school diploma or equivalent preferred.
One year of pre-certifications, medical billing, registration, healthcare experience, or other business or healthcare related education preferred.
Excellent oral communication skills/organizational skills
Ability to handle stress and problem solve
Computer experience required
Knowledge of Epic preferred
Able to work independently

Nice To Haves

One year of pre-certifications, medical billing, registration, healthcare experience, or other business or healthcare related education preferred.

Responsibilities

Identify all scheduled patients requiring pre-certification or pre-determination through various systems.
Identify all relevant patient data elements and information from the various systems to acquire precertification.
Contacts insurance companies or employer groups to obtain pre-certifications, predeterminations, and determine eligibility and benefits for necessary services.
Make necessary contact to follow up if there are insurance issues in order to obtain financial resolution.
Obtain necessary clinical documentation to use in the pre-certification process.
Coordinates follow-up timely to ensure procedures are authorized and documented prior to the date of service while ensuring all payor requirements are met to ensure payment.
Communicates with designated Mercy Partners, Patient Financial Counselors regarding outcome of pre-certifications, benefits and patient financial responsibility.
Obtains insurance information to complete payor requirements.
Maintains current knowledge of payor payment provisions and regulations.
Keep current of ICD-9/ICD-10 and CPT coding requirements.
Ability to utilize computer software to complete pre-certification processes.
Meets department productivity and accuracy expectations.
Understands and follows patient confidentiality policies.
Ability to determine network status, eligibility, and coverage for patients to ensure reimbursement for services.
Maintains current knowledge of payor payment provisions and regulations.
Communicate in a professional, respectful manner with provider offices regarding peer to peer information for follow-up ensuring authorizations can be obtained for procedures pended for medical review.
Follows documentation standards on all patient encounters on appropriate patient account utilizing notes.
Ensures account is updated to accurately reflect the current status.
Ability to work independently with minimal supervision and be result oriented.
Provide training and mentoring.
May be required to work alternate shifts, weekends and overtime during peak periods.
Participates in educational programs to meet mandatory requirements and identified needs with regard to position and personal growth.
Performs other duties as assigned.