Precertification Specialist

Mercy Health System•Janesville, WI

65d

About The Position

Responsible for correctly prioritizing and completing all steps of the scheduling, referral management, authorization, verification and registration process prior to patients receiving services. Identifies scheduling needs, reviews schedules, follows scheduling protocols and enters visit information for appropriate scheduling. Identifies, verifies, and captures appropriate patient demographic information and health insurance benefit eligibility information. Performs payer coverage investigation, as necessary, utilizing both internal and external tools and resources, to obtain reimbursement verification. Utilizes knowledge including, but not limited to, managed care, commercial, government, and work comp insurance billing requirements, as well as current coding guidelines and standards, to ensure resolution of pre-service edits, appropriate management of claims, initiation and direction of accounts for pre-authorization as required, prevention of timely filing claim denials, and procurement of appropriate reimbursement. This position requires understanding of healthcare Revenue Cycle and the importance of evaluating and securing all appropriate financial resources to maximize reimbursement to the health system. This position assumes clinical and financial risk of the organization when collecting and documenting information on behalf of the patient.

Requirements

High school diploma or equivalent required.
Two years of healthcare registration, scheduling, or physicians' office experience required.

Nice To Haves

Two years of customer service experience preferred.

Responsibilities

Ensures all scheduled visits are pre-registered and accounts are appropriately certified / authorized in advance of the service date.
Initiates, obtains, and documents referrals/authorizations/pre-certifications in appropriate systems.
Answers incoming external/internal telephone calls, determines purpose of calls and schedules appropriately or routes to physician practices or other departments as appropriate.
Registers new and returning patients via multiline phone lines, and various Mercy systems/applications for visits within the Mercyhealth System ensuring that all required elements are gathered to ensure payment for the service provided.
Initiates outbound calls to external providers, patients, and/or payers based on referrals entered into the system and schedules appropriately. Communicates with provider's office as needed.
Ensures compliance with Access and Revenue Cycle related policies and procedures.
Manages waitlists, rescheduling/cancellation of appointments as necessary.
Completes accounts in assigned WQ's.
Manages patient initiated scheduling requests through MyChart, Telehealth, or other self-scheduling applications.
Maintains a high level of professionalism and provides a quality patient experience.
Schedules appointments appropriately according to provider and clinic based protocols.
Performs ancillary tasks by providing outreach to patients. Must have excellent customer service skills.
Answers questions about organization and provides callers with address, directions and other information about the site that they are scheduled for.
Able to articulate information in a manner that patients, guarantors, and family members understand.
Ensures compliance with reporting related to demographics and federal and state requirements.
Has in depth knowledge of community based, state or federal government programs to provide assistance to patients who have limited or no ability to pay for their health care needs. Screens patients and provides assistance with completion of applications, if necessary.
Serves as a liaison to clinical staff by maintaining good communication regarding any problems and/or resolutions to patient issues or access concerns. Contacts insurance companies or employer groups via phone, web portals, electronic applications, or other appropriate means to determine eligibility and benefits for necessary services to obtain financial resolution and guarantee payment on account.
Maintains current knowledge of payor payment provisions and regulations to ensure correct data is gathered and documented.
Provides financial information to patients, which includes patient financial obligations, estimated costs of services, billing practices and establishing payment arrangements as necessary.
Collects co-pays, deductible and other out of pocket expenses via phone and/or in person and ensures patients understand their financial obligation and arrange for payment at the time of visit.
Must have a thorough understanding of patient payment options to be able to direct patients to appropriate resource for financial assistance programs. These programs may include Medicaid, Mercy Community Care and other community assistance as appropriate.
Advises department leadership of possible postponement or deferral of any elective/non-emergent service which have not been approved prior to service date.
Documents activity within appropriate EMR or patient accounting systems.
Complies with Mercyhealth Cash Handling and Collection Policies.
Demonstrates an understanding and follows patient confidentiality policies and all HIPAA Regulations.
Performs other clerical duties as needed such as faxing, filing and photocopying.
Subject matter expert with regards to assigned responsibilities.
Provides training to new partners, as well as on an as-needed basis.
Manages other duties as assigned.
Completes pre-registration and ensures appropriate referrals are in place and authorized.
Ensures compliance with Access and Revenue Cycle related policies and procedures.
Reviews external orders/referrals to ensure authorization and compliance requirements are met.
Assist with schedule utilization reports/documentation
Participates in workgroups related to access/scheduling improvements.
Notifies leadership of scheduling or access issues (time to next appt, provider cancellations, etc)
OPAM schedules for all specialties and modalities across the system.
OPAM Pre-Registration process is a different. As they are scheduling the patients and have them on the phone, they are reviewing their personal information and also checking on their insurance, is it in network, and additional verification. Triaging it a bit further as an example IF it is a worker's compensation and then follow additional information.
Promoting digital access and patient engagement to get them to leverage the capabilities that exist. (example: EPIC)
OPAM looks at the patient holistically, including current visit needs and then understanding additional needs of the patient and schedule them with another department.
Broader view of schedules to ensure coordination occurs throughout the whole system rather than at one physical location.
Ensure that Medical necessity is met.
Utilization of waitlists for the system to ensure that we are accelerating patients accessing system.
Focuses on schedule optimization by different area bringing in consistencies to services from a system perspective.
Looking for throughput optimizations as they work with different areas to maximize scheduling efficiencies across the system.
Needs the ability to understand multiple specialties and modalities and have the ability to support all of them.

Benefits

Mercyhealth offers a generous total rewards package to eligible employees including, but not limited to:
Comprehensive Benefits Package: Mercyhealth offers a retirement plan with competitive matching contribution, comprehensive medical, dental, and vision insurance options, life and disability coverage, access to flexible spending plans, and a variety of other discounted voluntary benefit options.
Competitive Compensation: Mercyhealth offers market competitive rates of pay and participates in various shift differential and special pay incentive programs.
Paid Time Off: Mercyhealth offers a generous paid time off plan, which increases with milestone anniversaries, to allow employees the opportunity for a great work-life balance.
Career Advancement: Mercyhealth offers a number of educational assistance programs and career ladders to support employees in their educational journey and advancement within Mercyhealth.
Employee Wellbeing: Mercyhealth has a focus on wellbeing for employees across the organization and offers a number of tools and resources, such as an employer-sponsored health risk assessment and a Wellbeing mobile application, to assist employees on their wellbeing journey.
Additional Benefits: Mercyhealth employees have access to our internal and external employee assistance programs, employee-only discount packages, paid parental and caregiver leaves, on-demand pay, special payment programs for patient services, and financial education to help with retirement planning.

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