Precertification Specialist | Central Scheduling | Memorial Health

Memorial Health•Marysville, OH

13d

About The Position

The Precertification Specialist 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 applicable Hospital Information System (HIS) authorization workqueues daily to ensure that tests and procedures requiring precertification are reviewed and completed on time, and reviews HIS reports for surgical case creation to proactively validate insurance network status before scheduling. The specialist notifies surgeon’s offices when insurance is out of network and advises that the patient’s financial responsibility will increase. The role includes submitting precertification through payor websites, fax, or telephone; confirming requests use the correct patient class and intended CPT or procedure codes; and reviewing medical records for clinical information to support requests. When required information is not in the HIS, the specialist requests it from the ordering provider’s office. The specialist scans determinations into the patient’s medical record and updates referral records with authorization status, communications, authorization and call reference numbers, and approval dates. The role also communicates available peer-to-peer options to ordering provider offices, verifies patient identity using three primary identifiers, helps prevent and reports duplicate medical record numbers, and reviews, transcribes, and distributes faxed documents as appropriate. This is a first-shift position with 80 hours per pay period. Memorial Health states its commitment to inclusivity and diversity and to providing a welcoming and inclusive environment for staff and guests.

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 and complete review of tests and procedures requiring precertification in a timely manner.
Review HIS reports for surgical case creation and validate insurance network status before cases are scheduled.
Notify surgeon’s offices of out-of-network insurance and advise that patient financial responsibility will increase.
Submit precertification through online payor websites, fax, or phone, as required by the insurance plan.
Ensure requests are submitted for the correct patient class and intended CPT or procedure codes.
Review patient medical records for clinical information supporting precertification requests, and request additional information from ordering provider offices when needed.
Scan precertification determinations into the patient’s medical record and update referral records with authorization status, communications, authorization numbers, call reference numbers, and approval dates.
Communicate available insurance precertification peer-to-peer options to ordering provider offices.
Identify patients using three primary identifiers; avoid duplicate MRN creation and report duplicate MRNs when discovered.
Review and transcribe faxed documents into the HIS and distribute faxed documentation to team members as necessary.