Precertification Specialist, Nucleus Building, 8a-430p

UofL Health•Louisville, KY

8d•Onsite

About The Position

The Precertification Specialist supports a positive patient experience for upcoming surgical procedures and diagnostic tests by completing steps related to prior authorization, medical necessity determination, and financial clearance for hospital and physician services across clinics, adult acute facilities, and diagnostic centers. The role involves reviewing scheduled procedures and medication orders, working with payers and providers, coordinating patient encounters across multiple systems, and documenting authorization and communication details accurately. The specialist also helps address patient and provider questions and coordinates peer-to-peer reviews, appeals, and follow-up when procedures are denied.

Requirements

High school diploma or equivalent.
At least one year of patient access, insurance verification, prior authorization, or related experience.
Ability to accurately and efficiently review clinical documentation and process authorizations in accordance with payer rules.
Ability to use multiple registration, clinical, eligibility-verification, and medical-necessity applications.
Ability to communicate professionally with patients, providers, payers, and clinical support staff.
Ability to prioritize work and meet productivity and accuracy standards.
Compliance with HIPAA privacy and security requirements.

Nice To Haves

Three years of prior authorization or related experience.
Medical terminology knowledge.
Healthcare experience.
Electronic Health Record experience.
Knowledge of EIPC.

Responsibilities

Identify the clinical documentation needed to support medical necessity for scheduled procedures and medication orders across service lines and clinics.
Submit authorizations and clinical information to the appropriate payer or benefit manager in a timely manner and in compliance with plan rules, including appropriate use of the CMS IP Only list.
Assess orders to determine appropriate patient class and work with physicians to clarify when necessary.
Contact insurance plans and payers to determine eligibility, procedure coverage, and benefit information.
Coordinate patient encounters using registration, clinical operating, eligibility verification, and medical necessity systems.
Document findings and communications accurately and thoroughly in the patient record.
Meet or exceed productivity standards and ensure accurate daily production.
Document authorization information accurately in referrals to support clean payer transactions.
Respond to communications through multiple applications in a timely and professional manner.
Comply with departmental and organizational policies, applicable laws and regulations, and accrediting-body requirements.
Prioritize work according to department, hospital, and patient needs.
Independently resolve patient and provider questions related to prior authorizations, referrals, and insurance verification.
Act as a liaison among patients, payers, providers, and clinical support staff.
Coordinate peer-to-peer reviews and appeals for providers according to plan guidelines and in a timely, professional manner.
Work with relevant parties to ensure patients are promptly rescheduled or notified of denials.
Stay current on payer regulations.
Provide patients and providers with accurate expected timeframes and payer guidelines for prior authorization and financial clearance.
Maintain compliance with company policies, procedures, standards of conduct, and HIPAA privacy and security requirements.
Perform other duties as assigned.