Precertification Specialist | Central Scheduling, Full-Time

Memorial Health Ohio•Paris Township, OH

4d•Onsite

About The Position

We are looking for a Precertification Specialist to join our collaborative team at Memorial Health! This role involves managing precertification processes, ensuring compliance with insurance requirements, and providing excellent patient experience. The specialist will handle incoming calls, gather patient information, verify insurance eligibility and benefits, and coordinate with healthcare providers and payors. Key responsibilities include submitting precertifications, tracking authorizations, and resolving any issues that arise during the process. The role also emphasizes patient communication, service recovery, and maintaining a professional and supportive work environment.

Requirements

High school diploma or equivalent
Personal computer/data entry experience preferred
Six months working in the healthcare environment preferred
Experience with Microsoft Word, Excel and Outlook preferred
Strong telephone and interpersonal communication skills
Teambuilding skills
Understanding of medical terminology and medical coding preferred
Excellent customer service skills

Nice To Haves

Personal computer/data entry experience
Six months working in the healthcare environment
Experience with Microsoft Word, Excel and Outlook
Understanding of medical terminology and medical coding

Responsibilities

Answers incoming phone calls within pre-established guidelines and accurately provide all relevant information to the callers.
Gathers pertinent patient information during patient or provider office interactions, including demographic, financial/guarantor information, MyChart activation and inputs information into the Hospital information system.
Ensures scheduling and authorization practices are consistent with internal policies and external requirements for expedient patient care and proper claims billing.
Contributes to the financial effectiveness of the Hospital by obtaining and/or reviewing scanned Medicare, Medicaid, and third-party insurance cards.
Instructs patient to bring insurance cards and photo ID for scheduled appointments.
Notifies patients of out-of-network insurance status when appropriate.
Completes medical necessity verification for Medicare outpatient tests and services that have Local Medical Review Policies (LMRP) / Local Coverage Determinations (LCD) in place and requests additional information from physician offices if needed to ensure compliance.
Completes verification of patient insurance plan eligibility and benefits utilizing the Hospital based eligibility system or web based technologies.
Proactively utilizes the MyCGS and MITS tools to determine Medicare / Medicaid coverage details.
Monitors scheduling workqueues and third-party referral websites daily to ensure ambulatory referrals and orders for testing are scheduled within expected timeframes.
Prioritizes urgent/emergent referrals and orders.
Reviews and transcribes faxed orders and referrals into the EMR accordingly.
Distributes faxed documentation as necessary to team members.
Provides clear instructions to patients and/or provider office regarding arrival time, location and any preparation required for appointments, procedures or testing.
Sends preparation instructions for procedures to patients at the point of scheduling.
Documents all incoming and outgoing communications (verbal and written) with patients, provider offices and insurance payors within the EMR.
Updates scheduling status, communication attempts and other relevant information within the EMR referral record and on third-party referral websites.
Informs Team Lead and Central Scheduling Management team of any significant delays in the scheduling process or patient experience issues.
Reschedules appointments timely due to department/resource availability or changes to provider schedules.
Places patients on waitlist as requested by the patient or ordering provider office.
Monitors the Central Scheduling Shared Inbox daily to ensure all inquiries are addressed timely.
Takes steps to avoid duplicate medical record creation and takes appropriate actions to report duplicate MRNs when discovered.
Communicates and coordinates scheduling with other hospital departments as needed for specific procedures/testing.
Inputs patient appointment recalls, completes recall report process monthly.
Sends reminder letters to patients for specific services.
Reviews precertification requirements at the point of scheduling for all procedures and/or testing scheduled by the department to ensure adequate time is given for precertification processing by the payor.
Completes timely submission of precertifications if required by the patient’s insurance plan(s) via online payor websites, fax or phone.
Reviews Referral Authorization workqueue daily to ensure testing requiring precertification is assigned to the appropriate staff member.
Requests additional clinical information from the ordering provider office if requested by the payor in order to complete the precertification process.
Notifies the patient and ordering provider office of any precertification delays and/or denials; rescheduling or canceling appointments if necessary.
Provides insurance precertification denial information to the ordering provider office and peer-to-peer options if made available by the payor.
Scans all precertification approvals or denials to the patient’s Medical Record and updates the referral record accordingly with authorization status, communications, approved/pending authorization numbers, call reference numbers and approval dates.
Updates or submits precertification upon request for urgent testing or in the event a test is changed on the date of service.
Reviews Central Scheduling shared inbox daily to check for appointments that do not have precertification information documented.
Upon request, reviews denied claims due to lack of prior authorization, submits retroactive submissions if permissible by the payor.
Closes the loop by communicating authorization status to Team Lead or Management Team.
Demonstrates willingness and ability to go above and beyond to answer patient inquiries regarding scheduling processes, insurance authorization issues, arrival instructions and test/procedure instructions.
Respectful and courteous during interactions with patients, families, payors or co-workers.
Demonstrates a strong representation of Memorial Health’s values through attitude, actions and communication with others.
Displays enthusiasm while applying quick thinking and resourcefulness in providing assistance to a variety of patient needs.
Connect patients with appropriate staff for testing/procedure cost estimates, financial assistance and HCAP.
Receives patient concerns and complaints and provides resolution for readily resolved issues and escalation for more in-depth issues as appropriate to assist with service recovery.
Ascertains and documents in the patient’s appointment and/or demographics any specific patient needs, including but not limited to, interpreter services, facilitation of transportation needs, equipment needed.
Makes reasonable attempts to schedule patients for appointments and testing based on the patient’s preference for date, time and location.
Maintains confidentiality at all times to protect patient privacy and adheres to HIPAA privacy and security regulations.
Acts as a resource for new employees and precepts as needed.
All interactions are conducted in a professional manner.
Demonstrates a positive attitude.
Provides excellent customer service, facilitates quality care delivery and fosters an atmosphere of understanding cultural diversity.
Communicates dissatisfaction with issues to Coordinator/Manager; actively contributes to the solution of problems and refrain from promoting dissatisfaction among co-workers.
Must be a team player; cooperate with co-workers to resolve conflict through one on one negotiation or with the assistance of the Coordinator/Manager or their designee.