Precertification Specialist JMC

Mercyhealth Wisconsin and Illinois•Janesville, WI

1d•Onsite

About The Position

This role involves identifying patients requiring pre-certification or pre-determination, reviewing patient schedules to acquire necessary data, and contacting insurance companies or employer groups to obtain pre-certifications, predeterminations, and determine eligibility and benefits for services. The specialist will follow up on insurance issues to achieve financial resolution and payment, obtain clinical documentation for the pre-certification process, and ensure timely documentation in appropriate systems. Responsibilities also include coordinating follow-up to meet payor requirements, communicating with Mercy Partners and Patient Financial Counselors regarding pre-certification outcomes and patient financial responsibility, and obtaining insurance information. The position requires maintaining current knowledge of payor payment provisions, regulations, ICD-9/ICD-10, and CPT coding requirements, assisting with denial appeals, and utilizing computer software for pre-certification. Participation in educational programs for mandatory requirements and personal growth is also expected. Mercyhealth is an integrated health system delivering coordinated care across seven hospitals and 85 primary and specialty clinics, serving northern Illinois and southern Wisconsin with a team of over 7,500 professionals. Mercyhealth has been nationally recognized for its commitment to its people and culture, including being #1 in the nation on AARP’s Best Employers for Workers Over 50, one of Working Mother magazine’s 100 Best Companies for Working Mothers, and a Top 50 Company and Top 10 Nonprofit for Executive Women. For over 135 years, Mercyhealth has provided high-quality health care, ranging from routine to highly specialized care.

Requirements

High school diploma or equivalent required.
One year of healthcare registration, scheduling, or physicians' office experience required.
Excellent oral communication skills.
Organizational skills.
Ability to handle stress & problem solve.
Computer experience required.
Able to work independently.

Nice To Haves

Completion of 24 (twenty four) hours of coursework in a business or healthcare related field of study may be considered in lieu of healthcare office experience.
Knowledge of Epic desirable.

Responsibilities

Identify all scheduled patients requiring pre-certification or pre-determination through various systems.
Review patient schedules & acquire all data elements & information from the various systems to acquire precertification.
Contact insurance companies or employer groups to obtain precertifications, predeterminations, & determine eligibility & benefits for necessary services.
Make necessary contact to follow up if there are insurance issues in order to obtain financial resolution & payment on account.
Obtain necessary clinical documentation to use in the pre-certification process.
Timely documentation of referrals/authorizations/pre-certifications in appropriate systems.
Coordinate follow-up to ensure all payor requirements are met & payment is expected.
Communicate with designated Mercy Partners, Patient Financial Counselors regarding outcome of precertifications, benefits & patient financial responsibility.
Obtain insurance information to complete payor requirements.
Maintain current knowledge of payor payment provisions & regulations.
Keep abreast of denials related to pre-certification & assist with appeal of denials as needed.
Keep current of ICD-9/ICD-10 & CPT coding requirements.
Ability to utilize computer software to complete pre-certification processes.
Participate in educational programs to meet mandatory requirements & identified needs with regard to position & personal growth.
Maintain logs & documents activity timely within patient accounting system.
Understand & follow patient confidentiality policies.
Additional duties as assigned or appropriate.