Precertification Specialist

Mercy Health Corporation
United States, Wisconsin, Janesville
Nov 15, 2024
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. Culture of Excellence Behavior Expectations To perform the job successfully, an individual should demonstrate the following behavior expectations: Quality - Follows policies and procedures; adapts to and manages changes in the environment; Demonstrates accuracy and thoroughness giving attention to details; Looks for ways to improve and promote quality; Applies feedback to improve performance; Manages time and prioritizes effectively to achieve organizational goals. Service - Responds promptly to requests for service and assistance; Follows the Mercyhealth Critical Moments of service; Meets commitments; Abides by MH confidentiality and security agreement; Shows respect and sensitivity for cultural differences; and effectively communicates information to partners; Thinks system wide regarding processes and functions. Partnering - Shows commitment to the Mission of Mercyhealth and Culture of Excellence through all words and actions; Exhibits objectivity and openness to other's views; Demonstrates a high level of participation and engagement in day-to-day work; Gives and welcomes feedback; Generates suggestions for improving work: Embraces teamwork, supports and encourages positive change while giving value to individuals. Cost - Conserves organization resources; Understands fiscal responsibility; Works within approved budget; Develops and implements cost saving measures; contributes to profits and revenue. 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. Certification and Licensure N/A Skills and Abilities Excellent oral communication skills/organizational skills Ability to handle stress and problem solve Computer experience required Knowledge of Epic desirable Able to work independently Special Physical Demands The Special Physical Demands are considered Essential Job Functions of the position with or without reasonable accommodations. While performing the duties of this job, the employee is regularly required to walk; use hands to finger, handle, or feel; reach with hands and arms; climb or balance; stoop, kneel, crouch, or crawl; and talk or hear. The employee is frequently required to sit and work at a computer for long periods of time. The employee is occasionally required to stand. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus. While performing the duties of this job, the employee must have good manual dexterity to operate keyboard and telephone; repetitive finger/wrist movement associated with use of keyboard; prolonged sitting. The employee must be able to lift or move office related objects Level of Supervision Some independent judgment is required, but alternatives are limited by standard practices or procedures. Supervises This position has no supervisory responsibility