Precertification Specialist Thursday - Monday

Northeast Georgia Medical Center•Gainesville, GA

About The Position

Under the supervision of the Utilization Review Manager, the Precertification Specialist obtains pre-certification approvals from insurance companies for inpatient and outpatient services. The role includes identifying insurance coverage and patient responsibility, verifying insurance, notifying payers of admissions, tracking approved days and required follow-up, and providing financial counseling when appropriate. The specialist works with clinical teams, physician offices, patients, and payers to secure authorizations, document account activity, and address delays or denials. The schedule is Thursday through Monday, with an eight-hour morning-to-afternoon shift.

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

Ensure scheduled and unscheduled inpatient and outpatient accounts are pre-authorized in advance or on the day of admission notification, following organizational and payer guidelines.
Provide and interpret clinical information from physicians, emphasizing medical justification for procedures during the pre-certification process.
Work with physician offices, Case Management, Utilization Review, and patients to obtain supporting clinical information 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 regarding authorization delays or denials.
Collaborate with Utilization Review nurses to obtain and fully document authorization for services in patient accounts.
Thoroughly document insurance verification and authorization activities in patient accounts.
Communicate with physician offices and payers to initiate and mediate physician-to-physician reviews.
Apply knowledge of payer requirements, procedure types, and plan types to determine when pre-authorization is required.
Document pre-certification accurately and promptly in the appropriate account.
Collaborate with the appeals department by providing information to help overturn 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, maximum delays, AUX times, abandonment rate, and ACD time.
Meet NGHS STARS customer-service standards and department goals, including productivity, accuracy, collections, and customer satisfaction.
Perform related duties as assigned and any additional department-specific duties deemed necessary by management.