Precertification Coordinator SA0209

Essential Functions

• All team members are expected to be knowledgeable and compliant with Prisma Health's values: Inspire health. Serve with compassion. Be the difference.

• Processes and tracks incoming referrals. Logs all incoming referrals according to program guidelines. Obtains medical records to support referrals. Prepares referral with clinical and financial information for submission to Program Director. Coordinates patient assignment to case management and communicates with referral source as to the status of the referral.

• Advocates for and secures coverage for all patients referred for services. Explains the unique aspects of the program to insurance representatives and provides the program description to all third-party payors in order to increase accuracy of pre-certification determinations and financial information. Verifies insurance benefits to include all possible services and codes billed by program and need for pre-certification or pre-authorization for treatment. Pursues any needed clarification of insurance benefits prior to scheduling of patients.

• Obtains staffing requirements related to third party payors based on requirements for in-network providers and communicates information to case management to maximize reimbursement.

• Maintains public relations with patients and third-party payors, including insurance case managers.

• Collects and verifies pertinent patient demographics and financial data on all new patient referrals with physician offices and other referral sources. Communicates with referral source to obtain additional information required for completing referral, including ICD-9 coding as well as ascertaining appropriate medical records to determine eligibility for program admission.

• Collects and verifies pertinent patient demographics and financial data on all ongoing patients under continuing treatment. Obtains continuing authorizations for treatment under 3rd party payor guidelines andtime framesand completes required documentation. Facilitates documentation needs by third party payors for continuing treatment. Provides initial advocacy and informational needs for recurring treatment withthirdparty payors and notifies case management ofadditionalcontact required.

• Performs compliance functions related to coding, billing, demographics and payor source. Facilitates codes on initial orders. Coordinates supplemental coding to support medical necessity of treatment and communicates to in a timely manner. Monitors timeliness of physician continuing orders for treatment for all program and patients.

• Coordinates patient scheduling process, updates waiting lists, prepares written communication to physicians regarding referrals and performs database entry.

• Performs other duties as assigned.