Precertification Specialist

PURPOSE:

The Precertification Specialist is responsible for the completion of precertification, prior authorization and notification for third party and government payers for all scheduled outpatient procedures and diagnostic testing. The Precertification Specialist is responsible for communicating with insurance companies, clinic staff, outside physician offices, facilities and patients to ensure authorizations are obtained in a timely manner.

ACCOUNTABILITIES AND JOB ACTIVITIES:

• Prioritize and process incoming authorization requests/orders
• Review clinical documentation to extract pertinent information which supports medical necessity
• Obtain patient benefit and eligibility status for pending procedures
• Communicate effectively with payers and third party utilization management companies to achieve positive outcomes
• Identify payer trends and provides feedback to the Billing Team Supervisor and providers
• Appeal denied authorizations when warranted
• Initiate peer to peer reviews and prepares documentation packets for the provider
• Maintain understanding of payer medical policies and guidelines
• Manage work queues, emails and phone messages timely and effectively

Develop and maintain personal and professional skills

• Attend all mandatory staff meetings per year unless excused as evidenced by documentation
• Attend mandatory in-services and a minimum of two pertinent in-services per year as documented
• Actively participate in performance improvement activities as observed or documented
• Establish realistic professional goals as evidenced by the annual performance evaluation
• Actively keep abreast of departmental and organizational activities
• Demonstrate flexibility in response to unexpected change in workload or situations as observed
• Serve on committees and/or participates in changes of policy and procedures that affect the revenue cycle
• Assist in the orientation of new personnel as directed
• Support the mission and goals of the company as observed
• Address all emails within 24 hours as documented
• Perform other duties as required

Demonstrate safe and cost-effective practice

• Consistently adhere to OSHA bloodborne pathogen guidelines; apply universal precautions per company standards as observed
• Consistently utilize proper body mechanics as observed
• Accurately complete incident reports within the shift of occurrence and immediately communicates critical incidents to the appropriate person per the organizational chart
• Consistently allocate resources to reduce waste and minimize costs as observed
• Consistently complete assigned duties within stated shifts in a timely manner as observed and documented

BEHAVIORAL EXPECTATIONS

Strive for excellence

• Set challenging goals
• Produce quality work in a timely fashion
• Maintain current knowledge and skill
• Participate in quality and process improvement efforts
• Keep the work area clean, safe and secure

Act Flexibly

• Adapt to change
• See the value of different opinions and new ideas
• Change plans and objectives given new direction or priorities
• Handle stressful situations effectively

Meet Customer Needs

• Meet internal and external customers needs
• Find new ways of satisfying customers
• Participate in service improvements efforts
• Listen and respond to customers
• Treat customers with compassion and respect

Work as a Team

• Work as a team player
• Pitch in to help those in need
• Communicate with others appropriately
• Listen and respond to others
• Handle conflict situations effectively
• Foster trust and respect within the team
• Participate in committees and task forces

Foster Diversity in the Workforce

• Treat all associates and customers with respect, integrity and dignity regardless of background, race, age, gender, gender identity, sexual orientation, religion or disability
• Treat all associates and customers fairly

Be Self-directed

• Take initiative and responsibility for actions
• Identify own learning needs and create/implement Learning Plans
• Perform duties according to policies and procedures
• Demonstrate ethical behaviors
• Maintain confidentiality of information
• Maintain licenses and certifications as appropriate
• Fulfill operating unit/clinical competencies
• Use equipment/resources responsibly

You must refer to upper management for approval or final disposition on the following

• Change in procedure
• Difficult patient situations
• Any situation you are unsure of

JOB SCOPE AND WORK ENVIRONMENT:

This position is subject to:

• Confidential information
• Extended time sitting at a desk, utilizing a keyboard and multiple monitors
• High stress environment due to turnaround requirements
• Daily hours are subject to change on a daily basis due to schedule

Patient Privacy HIPAA

• Protection of patient privacy
• Patient records and EMR are for treatment use only

The statements in this job description are intended to describe the essential nature and level of work performed by employees assigned to this job. They are not intended to be an exhaustive list of all responsibilities, duties and skills required of personnel so classified.

JOB REQUIREMENTS

OTHER REQUIREMENTS:

• Knowledge of common safety hazards and precautions to establish a safe work environment
• Must be able to act calmly and effectively in busy, stressful or emergency situations
• Ability to communicate effectively in person, by phone and in writing
• Requires adherence to all policies and procedures, including standards for safety, attendance, punctuality and personal appearance
• This position must be willing to do any additional tasks as assigned by management

PHYSICAL REQUIREMENTS:

HEARING: Adequate to perform job duties in person and over the telephone.

SPEAKING: Must be able to communicate clearly to patients & staff in person and over the telephone.

VISION: Requires eyesight correctable to 20/20 to operate equipment and read information from printed sources and computer screens.

OTHER: Requires frequent lifting and carrying items weighing up to 50 pounds unassisted, including assisting patients when required. Adequate physical ability to be present where needed.

Requires frequent bending, reaching, repetitive hand movements, standing, walking, squatting and sitting, with some heavy lifting, pushing and pulling exerted regularly throughout a regular work shift. Requires exposure to communicable diseases, bodily fluids, medicinal preparations and other conditions common to a clinic environment.

The above is intended to describe the general content and requirements for the performance for this position. It is not to be construed as an exhaustive statement of duties, responsibilities

or requirements. I have read the job description and understand the functions and objectives of the position at this company. This position must be willing to do any additional assignment by management.