You’ll need
Certifications
✓May provide back-up pre-certification/prior authorization resources for other departments as needed.
✓Works closely with Medical Staff, Payer Relations and Patient Financial Services to coordinate needed pre-certification authorizations for in-network services.
✓Maintains knowledge of current trends and developments as it relates to the pre-certification process.
Education
✓High school graduate or equivalent
Qualifications
✓One (1) year of medical insurance claims experience through patient accounts billing or claims adjudication
Full employer posting
- Responsible for the completion of pre-certification, prior authorization and notification for third party and government payers for all pre-scheduled elective inpatient and outpatient examination and procedures requiring preauthorization. May provide back-up pre-certification/prior authorization resources for other departments as needed. Coordinates/educates physicians, nursing staff and other health care providers on the pre-certification process and requirements. Tracks, documents, and monitors pre-certifications. Implements checks and balance systems to ensure compliance. Essential Job Functions
- Supports and practices the mission and philosophy of Billings Clinic and Radiology Department.
- Coordinates pre-certification process with provider offices to ensure target goal of 98% of pre-scheduled elective inpatient and outpatient procedures are pre-authorized.
- Documents and maintains patient specific pre-certification/authorization data within the required information systems. Compiles, documents, and tracks monthly pre-certifications using established procedures.
- Keeps undated list. Ensures correct patient status when pre-certifying.
- Reviews CPT-4 codes of required pre-certification and/or authorizations; ensuring Passport pre-certification process is also met.
- Reports denials and/or delays in the pre-certification process to physicians/other health care providers and the patient. May provide information to the patient on the appropriate appeal procedures for denials.
- Responsible for coordinating resolution of varied problem situations and performing necessary investigation and research to resolve pre-certification problems.
- Reports non-compliance issues and/or needs for program expansion to Manager.
- Works closely with Medical Staff, Payer Relations and Patient Financial Services to coordinate needed pre-certification authorizations for in-network services.
- Tracks and verifies receipt of pre-certification authorizations has been received either verbally or written. Communicates status to providers and patients as needed.
- Develops and maintains collaborative working relationships with payers and health care providers.
- Reviews, updates and standardizes forms and processes as needed
- Participates in interdepartmental meetings to coordinate efforts, work through processes, and foster communication.
- Develops and maintains reference manuals that outline the individual payer requirements as it relates to pre-certification and pre-authorization needs. Responsible for the integrity and accuracy of the payer data
- Assists patients/family members with status of pre-certification or re-certification information.
- Identifies needs and sets goals for own growth and development; meets all mandatory system/department requirements. Maintains knowledge of current trends and developments as it relates to the pre-certification process.
- Maintains competency in all organizational, departmental and outside agency environmental, employee or patient safety standards relevant to job performance.
- Performs other duties as assigned or needed to meet the needs of the department/organization.
- Education
- High school graduate or equivalent Experience
- One (1) year of medical insurance claims experience through patient accounts billing or claims adjudication
About the role
Responsible for the completion of pre-certification, prior authorization and notification for third party and government payers for all pre-scheduled elective inpatient and outpatient examination and procedures requiring preauthorization. May provide back-up pre-certification/prior authorization resources for other departments as needed.