Precertification Specialist Thursday - Monday

Northeast Georgia Health System•Gainesville, GA

About The Position

Under the supervision of the Utilization Review Manager, the Precertification Specialist provides customer service while obtaining pre-certification approvals from insurance companies for inpatient and outpatient services. The role includes identifying insurance coverage and patient responsibility, verifying insurance, providing admission notifications, identifying approved days, conducting required follow-up, and providing financial counseling when appropriate. The specialist works with physicians’ offices, Case Management, Utilization Review, patients, clinical staff, ancillary departments, and insurance payers to obtain clinical documentation and authorization, communicate delays or denials, and ensure accurate account documentation. The position also supports appeals and process improvement, handles incoming and outbound calls, and is expected to meet department productivity, accuracy, collections, and customer satisfaction goals.

Requirements

High school diploma or GED.
Ability to work independently, demonstrate emotional maturity, and function effectively under stress.
Excellent problem-solving and analytical skills.
Excellent written and oral communication skills.
Ability to prioritize, organize, and coordinate daily workload.
Working knowledge of Protected Health Information.
Ability to manage change.
Extensive knowledge of medical terminology.
Detailed understanding of insurance guidelines and protocols, full verification components, and payer information and requirements.

Nice To Haves

AAPC, AHIMA, or CPC certification strongly preferred.
Three to five years of relevant experience in insurance authorization, precertification, medical billing, revenue cycle, patient access, or related healthcare operations strongly preferred.

Responsibilities

Obtain pre-authorization for scheduled and non-scheduled inpatient and outpatient accounts, in advance or on the day admission is reported, according to organizational and payer guidelines.
Provide and interpret clinical information from physicians, emphasizing medical justification for procedures during the pre-certification process.
Coordinate with physician offices, Case Management, Utilization Review, and patients to obtain supporting clinical data for payer authorization.
Obtain complete and accurate insurance information and verify patient eligibility for inpatient and outpatient hospital visits.
Serve as a liaison among clinical staff, ancillary departments, patients, referring physician offices, and insurance payers, communicating authorization delays and denials.
Collaborate with Utilization Review nurses to obtain authorization for services and ensure it is fully documented in the patient account.
Document verification and authorization activities thoroughly and enter pre-certification information accurately and promptly in the appropriate account.
Communicate with physician offices and payers to initiate and mediate physician-to-physician reviews.
Apply knowledge of payer requirements by procedure and plan type to determine when pre-authorization is needed.
Work with the appeals department by providing information related to denied claims.
Monitor insurance authorization issues, identify trends, and participate in process improvement initiatives.
Handle incoming calls and meet department goals for outbound calls, speed to answer, delays, AUX times, abandonment rate, and ACD time, while meeting NGHS STARS customer service standards.
Meet department goals for productivity, accuracy, collections, and customer satisfaction.
Perform related duties as assigned, including additional department-specific duties as deemed necessary by management.