Precertification Specialist, UofL Health Physicians Outpatient, 9a-5p

UofL Health•Louisville, KY

10d•Onsite

About The Position

The Precertification Specialist helps ensure a positive patient experience for upcoming surgical procedures and diagnostic tests by completing prior authorization, medical necessity determination, and financial clearance steps for hospital and physician services across clinics, adult acute facilities, and diagnostic centers. The role identifies clinical documentation needed to support medical necessity, submits authorizations and clinical information to payers in accordance with plan rules, assesses orders to determine patient class, and works with physicians to clarify orders when needed. The specialist verifies eligibility, coverage, and benefits; coordinates patient encounters across multiple registration, clinical, eligibility, and medical-necessity systems; and accurately documents findings and authorization information in patient records and referrals. The role responds to communications and patient or provider questions, serves as a liaison among patients, payers, providers, and clinical support staff, and arranges peer-to-peer reviews or appeals. It also coordinates timely notification and rescheduling when procedures are denied, keeps current on payer regulations, and provides expected authorization timeframes and payer guidelines. The position requires compliance with departmental and organizational policies, applicable local, state, and federal regulations, accrediting-body requirements, and HIPAA privacy and security rules. The specialist prioritizes work according to department, hospital, and patient needs, meets or exceeds productivity standards, and performs other duties as assigned.

Requirements

High school diploma or equivalent.
At least one year of patient access, insurance verification, prior authorization, or related experience.

Nice To Haves

Three years of prior authorization or related experience.
Medical terminology knowledge.
Healthcare experience.
Electronic Health Record experience.
Knowledge of EIPC.

Responsibilities

Identify the clinical documentation needed to support medical necessity for scheduled procedures and medication orders across multiple service lines and clinics.
Submit authorizations and clinical information to the appropriate payer or benefit manager in a timely manner and in accordance with plan rules, including appropriate use of the CMS IP Only list.
Assess orders to determine the appropriate patient class and work with physicians to clarify orders as necessary.
Contact insurance plans and payers to determine eligibility, procedure coverage, and benefit information.
Coordinate patient encounters using multiple systems, including registration, clinical operating, eligibility-verification, and medical-necessity applications.
Document findings and communications thoroughly and accurately in the patient record, and record authorization information in referrals to support clean payer transactions.
Meet or exceed productivity standards for daily assignments and accurate production.
Respond to communications through multiple applications in a timely and professional manner.
Prioritize work according to department, hospital, and patient needs.
Independently resolve patient and provider questions related to prior authorizations, referrals, and insurance verification.
Act as a liaison among patients, payers, providers, and clinical support staff.
Arrange peer-to-peer reviews and/or appeals for providers promptly and professionally according to individual plan guidelines.
Work with relevant parties to ensure patients are promptly notified of denials and rescheduled as needed.
Stay current on payer regulations and accurately communicate expected timeframes and payer guidelines to patients and providers.
Comply with departmental and organizational policies and procedures, applicable regulations, accrediting-body requirements, company standards of conduct, and HIPAA privacy and security requirements.
Perform other duties as assigned.