Precertification Specialist, Nucleus Building, 8a-430p

UofL Health•Louisville, KY

11h•Onsite

About The Position

The Precertification Specialist supports a positive patient experience for upcoming surgical procedures and diagnostic tests by completing prior authorization, medical necessity determination, and financial clearance steps accurately and efficiently. The role serves hospital services and physician services across clinics, adult acute facilities, and diagnostic centers. The specialist identifies clinical documentation needed to support medical necessity, submits authorizations and clinical information to payers in accordance with plan rules, assesses orders to determine appropriate patient class, and works with physicians to clarify orders as needed. The role verifies eligibility, coverage, and benefits; coordinates patient encounters across multiple systems; and documents findings, communications, and authorization information accurately in the patient record and referrals. The specialist handles communications and questions from patients and providers, acts as a liaison among patients, payers, providers, and clinical support staff, and coordinates peer-to-peer reviews, appeals, and patient rescheduling or notification following denials. The role requires staying current on payer regulations and communicating authorization and financial-clearance timeframes and payer guidelines. The specialist must follow organizational policies, applicable regulations, accrediting-body requirements, and HIPAA privacy and security requirements.

Requirements

High school diploma or equivalent.
At least one year of patient access, insurance verification, prior authorization, or related experience.

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 multiple 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 orders as needed.
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 thoroughly and accurately in the patient record, and record authorization information in referrals as needed to support clean payer transactions.
Meet or exceed productivity standards for daily assignments and accurate production.
Respond to communications through multiple applications in a timely and professional manner.
Prioritize work according to department, hospital, and patient needs.
Independently resolve patient and provider questions concerning prior authorizations, referrals, and insurance verification.
Act as a liaison between patients, payers, providers, and clinical support staff.
Arrange peer-to-peer reviews and appeals for providers in a timely and professional manner according to individual plan guidelines.
Coordinate with relevant parties to ensure patients are promptly rescheduled or notified of denials.
Stay current on payer regulations and accurately communicate expected timeframes and payer guidelines to patients and providers.
Comply with organizational policies and procedures, local, state, and federal regulations, accrediting-body requirements, and HIPAA privacy and security requirements.
Perform other duties as assigned.