PRECERTIFICATION SPECIALIST

Overview

 Verification/certification of patient care services to ensure financial reimbursement. Responsible for insurance benefit verification and provision of clinical information for pre-certification for surgeries and other procedures and services as required by insurance companies. Interpret medical record documentation for patient history, diagnosis, and treatment options to facilitate authorizations. Communicates effectively and professionally with many stakeholders. Complete necessary forms for insurance companies and initiates appropriate follow-up. Process patient referrals to other specialties, both within Mercy Health System and to outside providers, if necessary. Utilizes excellent customer service by demonstrating written and oral communication skills. Documents thoroughly and according to department and health system expectations. This position requires moderate understanding of healthcare Revenue Cycle and the importance of evaluating and securing all appropriate financial resources to maximize reimbursement to the health system. This position assumes clinical and financial risk of the organization when collecting and documenting information on behalf of the patient. Performs other duties as assigned.

Responsibilities

Essential Duties and Responsibilities

• Identify all scheduled patients requiring pre-certification or pre-determination through various systems.
• Review patient schedules and acquire all data elements and information from the various systems to acquire precertification.
• Contacts insurance companies or employer groups to obtain precertifications, predeterminations, and determine eligibility and benefits for necessary services.
• Make necessary contact to follow up if there are insurance issues in order to obtain financial resolution and payment on account.
• Obtain necessary clinical documentation to use in the pre-certification process.
• Timely documentation of referrals/authorizations/pre-certifications in appropriate systems.
• Coordinates follow-up to ensure all payor requirements are met and payment is expected.
• Communicates with designated Mercy Partners, Patient Financial Counselors regarding outcome of precertifications, benefits and patient financial responsibility.
• Obtains insurance information to complete payor requirements.
• Maintains current knowledge of payor payment provisions and regulations.
• Keeps abreast of denials related to pre-certification and assist with appeal of denials as needed.
• Keep current of ICD-9/ICD-10 and CPT coding requirements.
• Ability to utilize computer software to complete pre-certification processes.
• Participates in educational programs to meet mandatory requirements and identified needs with regard to position and personal growth.
• Maintains logs and documents activity timely within patient accounting system.
• Understands and follows patient confidentiality policies.

Education and Experience

High school diploma or equivalent required.One year of healthcare registration, scheduling, or physicians' office experience required. Completion of 24 (twenty four) hours of coursework in a business or healthcare related field of study may be considered in lieu of healthcare office experience.

Benefits

Mercyhealth offers a generous total rewards package to eligible employees including, but not limited to: 

· Comprehensive Benefits Package: Mercyhealth offers a retirement plan with competitive matching contribution, comprehensive medical, dental, and vision insurance options, life and disability coverage, access to flexible spending plans, and a variety of other discounted voluntary benefit options.

· Competitive Compensation: Mercyhealth offers market competitive rates of pay and participates in various shift differential and special pay incentive programs.

· Paid Time Off: Mercyhealth offers a generous paid time off plan, which increases with milestone anniversaries, to allow employees the opportunity for a great work-life balance.

· Career Advancement: Mercyhealth offers a number of educational assistance programs and career ladders to support employees in their educational journey and advancement within Mercyhealth.

· Employee Wellbeing: Mercyhealth has a focus on wellbeing for employees across the organization and offers a number of tools and resources, such as an employer-sponsored health risk assessment and a Wellbeing mobile application, to assist employees on their wellbeing journey.

· Additional Benefits: Mercyhealth employees have access to our internal and external employee assistance programs, employee-only discount packages, paid parental and caregiver leaves, on-demand pay, special payment programs for patient services, and financial education to help with retirement planning.