Precertification Specialist

Mercy Health System Corporation•Lake Geneva, WI

About The Position

The Precertification Specialist identifies scheduled patients requiring pre-certification or pre-determination through various systems. This role involves identifying all relevant patient data elements and information from various systems to acquire precertification. The specialist contacts insurance companies or employer groups to obtain pre-certifications, predeterminations, and determine eligibility and benefits for necessary services. They also make necessary contact to follow up if there are insurance issues to obtain financial resolution, and obtain necessary clinical documentation for the pre-certification process. This role 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. The Precertification Specialist communicates with designated Mercy Partners and Patient Financial Counselors regarding the outcome of pre-certifications, benefits, and patient financial responsibility. They obtain insurance information to complete payor requirements and maintain current knowledge of payor payment provisions and regulations, as well as ICD-9/ICD-10 and CPT coding requirements. The ability to utilize computer software to complete pre-certification processes and meet department productivity and accuracy expectations is essential. Understanding and following patient confidentiality policies is also a key responsibility. The role requires the ability to determine network status, eligibility, and coverage for patients to ensure reimbursement for services. Communication in a professional, respectful manner with provider offices regarding peer to peer information for follow-up is necessary to ensure authorizations can be obtained for procedures pended for medical review. Documentation standards are followed on all patient encounters on appropriate patient accounts utilizing notes, and accounts are updated to accurately reflect the current status. The ability to work independently with minimal supervision and be result-oriented is important. Training and mentoring may be provided. This position may be required to work alternate shifts, weekends, and overtime during peak periods. Participation in educational programs to meet mandatory requirements and identified needs is expected. Other duties as assigned.

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.

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.