Pre Certification Specialist

Responsibilities

• To perform all activities related to third-party payer pre-certification requirements to meet the daily pre-certification functions at Dreyer Medical Clinic.
• Completes pre-certification process or transfers call as appropriate.
• Upon completion of the pre-certification process, enters authorization number in the order and closes encounter.
• Monitors all Peer-to-Peer pre-certification decisions forwarded by RN Nurse Specialist and closes case with appropriate determination from pre-certification vendor.
• Verifies per insurance type and service requested the need for pre-certification. Notifies the Business Office when patients with No Insurance or Termed Insurance are identified.
• Reviews pended order for completeness and accurate coding.
• Contacts the pre-certification vendor and provides the facility and patient demographic information.
• Monitor future orders and assure completion of pre-certification process by due date of procedure.
• Identifies orders placed outside the number of days determined valid by the pre-certification vendor and postpones those orders in EPIC using postpone function or staff message function.
• Serves as an advocate and liaison between patients, associates, physicians and external customers by sharing necessary information to ensure continuity of care.
• Completes all patient documentation within the defined time frame and consistently completes pre-certification with all appropriate information.

• High school diploma or GED
• 2 years experience in a medical office setting performing related duties/functions.

• Professional communication and interpersonal skills.
• CRT/PC experience in a customer service setting.
• Ability to type with good accuracy.
• Familiar with MS Word, Excel, and Outlook.
• Ability to solve problems posed by callers seeking pre-certification authorizations
• Proven ability to handle difficult callers, customers and/or patients.
• Knowledge of medical terminology and ICD-9, HCPCS, CPT coding.

• Must be able to successfully complete clinic-based training for all associates.
• Ability to work with all levels of personnel.
• Ability to work under stressful situations.
• Frequent periods of extended sitting.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.