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

UofL Health•Louisville, KY

11d•Onsite

About The Position

The Precertification Specialist supports 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 reviews clinical documentation and orders, submits authorization requests, verifies coverage and eligibility, coordinates patient encounters across multiple systems, and records findings and communications accurately. The specialist also helps resolve patient and provider questions, coordinates peer-to-peer reviews and appeals, and ensures patients are notified promptly of denials or rescheduling needs.

Requirements

High school diploma or equivalent.
At least one year of patient access, insurance verification, prior authorization, or related experience.
Comply with HIPAA privacy and security requirements and maintain confidentiality.
Ability to coordinate work across multiple systems and applications.

Nice To Haves

Three years of prior authorization or related experience.
Knowledge of medical terminology.
Healthcare experience.
Electronic health record experience.
Knowledge of EIPC.

Responsibilities

Identify clinical documentation needed to support medical necessity for scheduled procedures and medication orders across multiple service lines and clinics.
Submit authorization requests and clinical information to appropriate payers or benefit managers promptly and in accordance with plan rules, including proper use of the CMS Inpatient Only list.
Assess orders to determine appropriate patient class and consult physicians for clarification when necessary.
Contact insurance plans and payers to determine eligibility, procedure coverage, and benefit information.
Coordinate patient encounters using registration, clinical, eligibility verification, and medical necessity applications.
Document findings and communications thoroughly and accurately in patient records.
Meet or exceed productivity standards and complete daily assignments accurately.
Record authorization information in referrals to support clean transactions with payers.
Respond to communications through multiple applications in a timely and professional manner.
Comply with departmental and organizational policies, local, state, and federal regulations, and accrediting-body requirements.
Prioritize work according to department, hospital, and patient needs.
Independently resolve patient and provider questions regarding prior authorizations, referrals, and insurance verification.
Act as a liaison among patients, payers, providers, and clinical support staff.
Arrange peer-to-peer reviews and appeals for providers promptly and professionally according to plan guidelines.
Coordinate with necessary parties to ensure patients are promptly notified of denials or rescheduled.
Stay current on payer regulations and provide patients and providers with accurate authorization and financial-clearance timeframes and payer guidelines.
Maintain compliance with company policies, procedures, standards of conduct, and HIPAA privacy and security requirements.
Perform other duties as assigned.