Precertification Specialist 1

Mercyhealth Wisconsin and Illinois•Home, WV

1d•$18 - $28•Remote

About The Position

The Precertification Specialist 1 identifies patients requiring pre-certification or pre-determination, verifies insurance eligibility and benefits, obtains clinical documentation, and secures authorizations before the date of service. The role maintains accurate patient account documentation and communicates with insurance companies, provider offices, Mercy Partners, and Patient Financial Counselors to resolve coverage issues and support reimbursement while following payer requirements and patient confidentiality policies. The specialist meets productivity and accuracy standards, works independently with limited supervision, and provides training and mentoring. The position is remote and full-time, scheduled for 40 hours per week. Alternate shifts, weekends, and overtime may be required during peak periods.

Requirements

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

Nice To Haves

Knowledge of Epic preferred.
High school diploma or equivalent preferred.
One year of pre-certification, medical billing, registration, healthcare experience, or other business- or healthcare-related education preferred.

Responsibilities

Identify scheduled patients requiring pre-certification or pre-determination through various systems.
Identify relevant patient data and information needed to acquire pre-certification.
Contact insurance companies or employer groups to obtain pre-certifications and pre-determinations and determine eligibility and benefits.
Follow up on insurance issues to obtain financial resolution.
Obtain clinical documentation necessary for the pre-certification process.
Coordinate timely follow-up so procedures are authorized and documented before the date of service and payer requirements are met.
Communicate pre-certification outcomes, benefits, and patient financial responsibility to designated Mercy Partners and Patient Financial Counselors.
Obtain insurance information to complete payer requirements.
Maintain current knowledge of payer payment provisions and regulations, as well as ICD-9/ICD-10 and CPT coding requirements.
Use computer software to complete pre-certification processes.
Meet department productivity and accuracy expectations.
Follow patient confidentiality policies.
Determine network status, eligibility, and patient coverage to support reimbursement for services.
Communicate professionally and respectfully with provider offices about peer-to-peer information and follow-up for procedures pended for medical review.
Document all patient encounters in the appropriate patient account and keep account status accurate.
Work independently with minimal supervision and remain result oriented.
Provide training and mentoring.
Work alternate shifts, weekends, and overtime during peak periods if required.
Participate in educational programs to meet mandatory requirements and support position-related and personal growth.
Perform other duties as assigned.