Precertification Specialist

• Precertification Specialist, Patient Access, Days, 80 Hrs / 2 wks
• Location: MercyHealth - Janesville.

Verification of coverage and certification of scheduled patient care services to ensure financial reimbursement. Responsible for insurance benefit verification and provision of clinical information for pre-certification for scheduled surgeries and other procedures and services as required by insurance companies. Review and interpret clinical documentation for patient history, diagnosis, and treatment options to facilitate authorizations. Communicates effectively and professionally with many stakeholders. Utilize various technologies and workflows to initiate and obtain authorizations for scheduled procedures prior to the date of service. Perform all necessary follow-up with insurance companies and providers to ensure scheduled procedures are authorized to ensure reimbursement for services. 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 thorough knowledge base of medical terminology and the 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.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Identifies all scheduled patients requiring pre-certification or pre-determination through various systems.
• Identifies all relevant patient data elements and information from the various systems to acquire pre-certification.
• Contacts insurance companies or employer groups to obtain pre-certifications, predeterminations, and determine eligibility and benefits for necessary services.
• Makes the necessary contact to follow up if there are insurance issues or changes in order to obtain financial resolution. Obtains necessary clinical documentation to use in the pre-certification process.
• Coordinates follow-up timely to ensure procedures are authorized and documented prior to the date of service while ensuring all payor requirements are met to ensure payment.
• Communicates with designated Mercyhealth Partners regarding outcome of pre-certifications,
• Obtains insurance information to complete payor requirements.
• Maintains current knowledge of payor payment provisions and regulations.
• Keeps current of ICD-9/ICD-10 and CPT coding requirements.
• Utilizes computer software to complete pre-certification processes.
• Meets department productivity and accuracy expectations.
• Understands and follows patient confidentiality policies.
• Has advanced knowledge of determining network status, eligibility, and coverage for patients to ensure reimbursement for services. Maintains and reports current knowledge of payor payment provisions and regulations.
• Communicates in a professional, respectful manner with provider offices regarding peer to peer information for follow-up ensuring authorizations can be obtained for procedures pended for medical review.
• Follows documentation standards on all patient encounters on appropriate patient account utilizing notes. Ensures account is updated to accurately reflect the current status.
• Works independently with minimal supervision and be result oriented.
• Provides training and mentoring.
• Prioritizes multiple requests requiring authorization by review of type of procedure, type of insurance coverage, and date of service.
• Multitasks and remains focused while managing a high-volume, time-sensitive workload efficiently.
• Has effective interpersonal skills, including the ability to promote teamwork.
• Has advanced knowledge of precertification process, workflows and department policies.
• Provides shadowing opportunities for partners.
• Acts as a resource for fellow partners who are seeking guidance in the absence of a Training Coordinator, Lead, Supervisor, or Manager.
• Identifies and attends additional education opportunities to increase job specific knowledge base.
• May be required to work alternate shifts, weekends and overtime during peak periods.
• Participates in educational programs to meet mandatory requirements and identified needs with regard to position and personal growth.
• Performs other duties as assigned.

EDUCATION AND EXPERIENCE

High school diploma or equivalent preferred.
Two years of pre-certifications, medical billing, registration or other healthcare experience required.
Advanced knowledge of commercial and government payers required
Advanced knowledge of medical terminology required
General knowledge of CPT coding

CERTIFICATION AND LICENSURE

Healthcare revenue cycle related certification or an equivalently designated certification approved by management required.

Mercyhealth offers a generous total rewards package to eligible employees including, but not limited to:

* Comprehensive Benefits Package: Mercyhealth offers a retirement plan with competitive matching contribution, comprehensive medical, dental, and vision insurance options, life and disability coverage, access to flexible spending plans, and a variety of other discounted voluntary benefit options.

* Competitive Compensation: Mercyhealth offers market competitive rates of pay and participates in various shift differential and special pay incentive programs.

* Paid Time Off: Mercyhealth offers a generous paid time off plan, which increases with milestone anniversaries, to allow employees the opportunity for a great work-life balance.

* Career Advancement: Mercyhealth offers a number of educational assistance programs and career ladders to support employees in their educational journey and advancement within Mercyhealth.

* Employee Wellbeing: Mercyhealth has a focus on wellbeing for employees across the organization and offers a number of tools and resources, such as an employer-sponsored health risk assessment and a Wellbeing mobile application, to assist employees on their wellbeing journey.

* Additional Benefits: Mercyhealth employees have access to our internal and external employee assistance programs, employee-only discount packages, paid parental and caregiver leaves, on-demand pay, special payment programs for patient services, and financial education to help with retirement planning.