Precertification Specialist WMCG

Wellstar Health System

22h • Onsite

About The Position

The Outpatient Infusion (OPIC) Pre-Authorization Specialist functions under the direction of the OPIC Manager. Provides outstanding customer service to customers in a fast-paced busy environment. Drive volumes and increase revenue by obtaining Pre-Authorization for Outpatient Infusion in a timely Manner. Observing Quality and Productivity standards and other Key Performance Indicators. Responsible for performing a wide variety of clerical procedures that requires independent judgment, ingenuity and initiative in the utilization of computers and other equipment. Knows the existing lines of communication and authority, handles communications properly and is dependable and cooperative. Works with staff and understands appropriate scheduling and authorization process, willing to learn procedures/patient preps. Assist Scheduling, patient and physician's office staff with authorization issues in a timely manner. Communicate any authorization issues with the patient and provider within 24 hours of the patients' appointment. Make all efforts to avoid Denials, assist with Denials, claim edits, and reconsiderations when needed. Support Revenue cycle. Must be flexible with work hours to meet department needs.

Requirements

• High School Diploma or GED
• 1 year or more of experience in Patient Access or Revenue Cycle.
• Experience with databases, spreadsheets, operating systems required.
• Strong customer service skills, communication skills and organizational skills.
• Basic typing and data entry experience.
• Experience in computer usage and Medical Terminology preferred.
• The individual must be able to communicate and understand verbal and written English language and display a positive attitude (see WellStar's Standards of Gold and Values).
• This position requires a high level of attention to detail and a low error rate, as the consequences of even a minor mistake can be significant for patients and providers.
• In addition, this position requires regular, reliable attendance.

Nice To Haves

• Medical Terminology preferred.

Responsibilities

• Knowledge of all Outpatient Infusion exams in all modalities, including patient preps and instructions.
• Demonstrate understanding of scheduling/Outpatient infusion.
• Knowledge of CPT codes, Diagnosis codes and/or reasons for procedures (ICD-10)
• Knowledge of testing frequencies based on insurance and Medicare guidelines.
• Knowledge of various insurance programs offered by each carrier (TPA)
• Knowledge of Medicare guidelines regarding infusions that require Medical necessity checks
• Knowledge of insurance carriers requirements for Pre-Authorization of procedures and referrals for procedures.
• Knowledge of the lead time required by an insurance carrier to process pre-auth referral numbers.
• Assist the physicians office with ICD-9 and ICD-10 codes for Medicare Medical necessity by referring to the coding helpline
• Assist the physicians offices with pre-authorization process
• Knowledge of electronic orders (Epic, Image Now, Trace)
• Provides appropriate telephone etiquette and scripting.
• Ability to type with a high degree of accuracy and computer skills to accurately input data, Pre-authorization referral number in the appropriate field in Epic to ensure claim is generated in a timely manner.
• Maintain accurate and thorough notes when updating authorization status.
• Obtain pre-authorization numbers from physicians offices on all required procedures.
• Excellent communication and interpersonal skills to effectively deliver pending preauthorization issues to the patient, their representatives, facility and/or physician offices in a timely manner to eliminate potential revenue loss, customer satisfaction issues, patient responsibility. Explain available options (ABN, reschedule, Peer to Peer, insufficient information, Financial Responsibility form etc)
• Observe the guidelines of the authorization Policy & Procedure when communicating Authorization status to our customers
• Verify the accuracy of data entered and correct any errors
• Superior attention to detail
• Assist with monthly reports as requested
• Keeps current with insurance requirements for preauth
• Working knowledge of assigned referral work queues
• Responsible for meeting the demands of the assigned facility schedule.
• Assists with work queues as requested (Claim Edits, Accounts, etc)
• Assume other duties as needed to support the staffing needs of the department (May be delegated on a daily basis)
• Ability to exercise judgment in taking appropriate actions in emergent situations, take initiative when problem solving, retain composure in stressful situations and escalate issues as necessary
• Maintain neat attire, hair and appearance, following the department dress code.
• Acts in a way that demonstrates deep personal integrity and serves as a positive example.
• Customer Focus Engagement (Internal and External Customers)
• Ability to interact respectfully with co-workers, patients, referring office staff in a friendly, personable and professional manner
• Promote positive working relationships with co-workers, Team Leads, Supervisors and Managers.
• Orientates new employees and assures proper documentation of training
• Assists other areas when needed
• Flexible with hours to meet department needs
• Assist in the interview process of new hires if asked
• Understands existing lines of communication and authority, handles communications properly and is dependable and cooperative
• Meets Service Recovery and Customer Service guidelines as needed
• Initiate escalation process if authorization cannot be obtained.
• Views oneself as a reflection of the organization by following through on commitments and accepting ownership of any mistakes he/she might make.
• Work collaboratively with the team to determine areas of optimization and develop solutions
• Takes responsibility for own actions, including the impact of those decisions on patients and others.
• Keep current knowledge of lead time required by insurance carriers to process preauth request.
• Assist Supervisor with training of new employees
• Analyze patient medical records
• Responsible for obtaining all necessary patient demographics, insurance, and financial information; verifying insurance eligibility and benefits; ensuring pre-certification and authorization is obtained and validated; computing, communicating and initiating patient liability collections for scheduled patients prior to date of service across all hospital ancillary, ambulatory clinic and Labor and Delivery patients, as well as for hospital direct admits.

Benefits

• Nationally ranked and locally recognized for our high-quality care and inclusive culture, Wellstar is one of Georgia’s largest and most integrated healthcare systems.
• Every day, 24,000+ of us work together to provide personalized care for patients at every age and stage of life – and our team members are the foundation of that care.
• Mission, Vision & Values At a time when the healthcare industry is changing rapidly, Wellstar remains committed to exceeding patients’ and team members’ expectations, while transforming healthcare delivery.
• OUR MISSION: To enhance the health and well-being of every person we serve.
• OUR VISION: Deliver world-class healthcare to every person, every time.
• OUR VALUES: We serve with compassion We pursue excellence We honor every voice
• Culture of Excellence Wellstar consistently receives attention and accolades from national organizations that set the standards for world-class care.
• Our system-wide practice of safety principles, assessing and addressing errors and seeking feedback from our patients and customers continually earns recognition for advances in safety and quality.
• Featured on the FORTUNE “100 Best Companies to Work For” list and Seramount 100 Best Companies list, we not only provide top-notch care for our patients, but also foster the culture of Wellstar as a Great Place to Work.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED