Precertification Specialist

Overview

• Hybrid and flexible work schedule opportunities available after probationary period.
• Precertification Specialist, Patient Access, Days, 80 hrs / 2 wks
• Location:
  
  Mercyhealth Janesville, WI

Responsible for correctly prioritizing and completing all steps of the scheduling, referral management, authorization, verification and registration process prior to patients receiving services. Identifies scheduling needs, reviews schedules, follows scheduling protocols and enters visit information for appropriate scheduling. Identifies, verifies, and captures appropriate patient demographic information and health insurance benefit eligibility information. Performs payer coverage investigation, as necessary, utilizing both internal and external tools and resources, to obtain reimbursement verification.

Utilizes knowledge including, but not limited to, managed care, commercial, government, and work comp insurance billing requirements, as well as current coding guidelines and standards, to ensure resolution of pre-service edits, appropriate management of claims, initiation and direction of accounts for pre-authorization as required, prevention of timely filing claim denials, and procurement of appropriate reimbursement. This position requires understanding of healthcare Revenue Cycle and the importance of evaluating and securing all appropriate financial resources to maximize reimbursement to the health system.

• Ensures all scheduled visits are pre-registered and accounts are appropriately certified / authorized in advance of the service date.
• Initiates, obtains, and documents referrals/authorizations/pre-certifications in appropriate systems.
• Answers incoming external/internal telephone calls, determines purpose of calls and schedules appropriately or routes to physician practices or other departments as appropriate.
• Registers new and returning patients via multiline phone lines, and various Mercy systems/applications for visits within the Mercyhealth System ensuring that all required elements are gathered to ensure payment for the service provided.
• Initiates outbound calls to external providers, patients, and/or payers based on referrals entered into the system and schedules appropriately. Communicates with provider's office as needed.
• Ensures compliance with Access and Revenue Cycle related policies and procedures.
• Manages waitlists, rescheduling/cancellation of appointments as necessary.
• Completes accounts in assigned WQ's.
• Manages patient initiated scheduling requests through MyChart, Telehealth, or other self-scheduling applications.
• Maintains a high level of professionalism and provides a quality patient experience.
• Schedules appointments appropriately according to provider and clinic based protocols.
• Performs ancillary tasks by providing outreach to patients. Must have excellent customer service skills.
• Answers questions about organization and provides callers with address, directions and other information about the site that they are scheduled for.
• Able to articulate information in a manner that patients, guarantors, and family members understand.
• Ensures compliance with reporting related to demographics and federal and state requirements.
• Has in depth knowledge of community based, state or federal government programs to provide assistance to patients who have limited or no ability to pay for their health care needs. Screens patients and provides assistance with completion of applications, if necessary.
• Serves as a liaison to clinical staff by maintaining good communication regarding any problems and/or resolutions to patient issues or access concerns. Contacts insurance companies or employer groups via phone, web portals, electronic applications, or other appropriate means to determine eligibility and benefits for necessary services to obtain financial resolution and guarantee payment on account.
• Maintains current knowledge of payor payment provisions and regulations to ensure correct data is gathered and documented.
• Provides financial information to patients, which includes patient financial obligations, estimated costs of services, billing practices and establishing payment arrangements as…