Precertification Specialist | Central Scheduling | Memorial Health

Memorial Health Ohio•Paris Township, OH

20d

About The Position

The Precertification Specialist works in Central Scheduling and reviews precertification requirements and submits requests for advanced imaging, elective inpatient admissions, endoscopy, multipurpose cath lab, non-invasive cardiovascular lab, sleep studies, and surgical services. The specialist reviews authorization workqueues and surgical case reports in the Hospital Information System (HIS), confirms insurance network status before cases are scheduled, and submits required precertification requests through payor websites, fax, or phone. The role involves reviewing medical records and requesting additional clinical information from ordering provider offices when needed. The specialist records precertification determinations and authorization details in the patient’s medical record and referral record, communicates available peer-to-peer options to provider offices, verifies patient identity using three primary identifiers, and helps prevent or report duplicate medical record numbers. The specialist also reviews and transcribes faxed documents into the HIS and distributes documentation to team members as needed.

Requirements

High school diploma or equivalent.
Strong telephone and interpersonal communication skills.
Teambuilding skills.
Excellent customer service skills.

Nice To Haves

Personal computer and data entry experience.
Six months of experience working in a healthcare environment.
Experience with Microsoft Word, Excel, and Outlook.
Understanding of medical terminology.
Knowledge of medical insurance precertification.

Responsibilities

Review precertification requirements and submit requests for advanced imaging, elective inpatient admissions, endoscopy, multipurpose cath lab, non-invasive cardiovascular lab, sleep studies, and surgical services.
Review HIS authorization workqueues daily to ensure services requiring precertification are reviewed and completed in a timely manner.
Review HIS reports for surgical case creation and proactively validate insurance network status before scheduling cases.
Notify surgeon’s offices when insurance is out of network and advise that the patient’s financial responsibility will increase.
Submit precertification requests in a timely manner through payor websites, fax, or phone, ensuring the correct patient class and intended CPT/procedure codes are used.
Review patient medical records for clinical information supporting precertification requests and request additional information from ordering provider offices when needed.
Scan precertification determinations to the patient’s medical record and update referral records with authorization status, communications, authorization or call reference numbers, and approval dates.
Communicate payor-provided peer-to-peer options to ordering provider offices.
Verify patient identity using three primary identifiers and avoid or report duplicate medical record numbers.
Review and transcribe faxed documents into the HIS and distribute faxed documentation to team members as necessary.