Precert Specialist

POSITION SUMMARY

• Responsible for submitting/obtaining any required authorization/notification for tests performed; to insure proper reimbursement of claims.

• Also responsible for scheduling patients for tests.

OVERVIEW

• The evaluation is to assure individual performance, departmental goals and organizational goals are aligned. It is designed to support communication between the manager and the employee. Employee perception of their own performance is very important. To maximize the benefit of this process, both the manager and the employee participate in the evaluation process.

QUALIFICATIONS

A. Knowledge, Skills and Abilities

• Excellent customer service skills.

• Reads and understands the English language.

• Ability to think critically and analytically with little or no supervision

• Ability to work effectively in situations of high stress and conflict and communicate goals and outcomes.

• Ability to process information and prioritize

• Possesses exceptional verbal and written communication skills

• Possesses independent work habits, is self-reliant and self-directed

• Ability to learn, adapt, and change as required by the job functions

• Ability to maintain absolute confidentiality of material and information accessed and reviewed

• Basic computer literacy

• Ability to move freely, reach, bend, and complete light lifting

• Ability to use good body mechanics while performing daily job functions and ability to follow specific OSHA guidelines

• Ability to maintain attendance to meet standard job practices

B. Education

• High School Graduate or G.E.D. required.

C. Licensure

• LPN, Medical Billing/Coding or Prior Years Equivalent

D. Experience

• Minimum of five years experience is required in medical or financial field.

• Pre-certification experience preferred.

E. Interpersonal skills

F. Essential technical/motor skills

G. Essential physical requirements

• Sedentary: Exert up to 10 lb. of force occasionally and/or a minute amount frequently - >75%

H. Essential mental requirements

I. Essential sensory requirements

J. Other

• Basic understanding of Medicaid, Medicare and Commercial Insurance guidelines.

• Analytical and organizational skills must be above average.

• Attention to detail, communication, and documentation skills must be excellent.

• Prior public relation experience is required.

• Operations of computer systems and business machinery also required.

• Must have the ability to communicate in a courteous manner and possess excellent telephone communication skills with the ability to remain calm in difficult situations.

• Must have the ability to talk with public in a professional manner and be able to interpret patient clinical information, charges and explain in detail.

• Must have excellent interpersonal communication skills and possess professional and neat appearance.

K. Equipment used

OTHER QUALIFICATIONS

A. Exposure to hazards (body fluid exposure level)

• Level III

B. Age of Patient Populations Served

• Adolescents 13 - 18 years

• Adults 19 - 70 years

• Geriatrics - 70+ years

JOB SPECIFIC DUTIES AND PERFORMANCE STANDARDS

• Below are those tasks, duties, and responsibilities that comprise the means of accomplishing the position’s purpose and objectives. These are critical or fundamental to the performance of the position. They are the major functions for which the person in the position is held accountable. Following are the essential functions of the position, along with the corresponding performance standards.

o Major Task, Duties, and Responsibilities

 Initiates contact to insurance company, including use of internet to obtain correct patient benefit information, including deductible and co insurance amount of patient liability and certification requirements.

 Responsible for contacting insurance company or authorized representative to provide clinical information needed to obtain authorization for medical services to be provided by CRMC.

 Responsible for obtaining needed clinical information from physician office to facilitate authorization requirements, by maintaining open communication with physician offices.

 Responsible for updating schedule and contacting patient and physician office with necessary changes due to authorization requirements.

 Ensure all physician orders meet current standards and policies. Obtain clarification of orders from physician office.

 Responsible for cross training in Patient Access registration and must accurately update patient demographic and insurance information as necessary when patient contact is possible.

 Determines primary insurance liability in cases requiring coordination of benefits (spouse, dependent child).

 Initiates communication to coworkers in the event of limited or lack of insurance benefits.

 Maintains acceptable accuracy rate based on Patient Access guidelines. Obtains education and reviews accuracy as needed and provided by Patient Access Quality Assurance personnel.

 Responsible for cross training in Scheduling in order to assist co workers during absences and as workload needs arise.

 Reviews prior accounts and makes recommendations for their resolution as defined in hospital's policy and procedures.

 Refers potential Medicaid patients to Medicaid Benefit Specialist for screening process.

 Notifies the physician's office of any potential delay or change in procedure due to certification requirements. Ensure all physician orders meet current standards and policies. Obtain clarification of orders from physician office.

 Documents all contact with patients, family, employers and third party payers in the appropriate HIS system.

 Continues to stay informed of any policy or regulation changes that could affect collection of receivables. Updates personal manual with current revisions of policies, reviews Communication Board and monitors electronic mail for current regulations.

 Answers telephone professionally and courteously. Answers all inquiries in a courteous and timely manner.

 Documents all patient complaints through use of appropriate system.

 Understands the significance of the organization's Performance Improvement Programs and is an active participant.

 Complies with all departmental policies of Patient Access.

 Reports any problems to immediate supervisor daily as needed.

 Responsible for any and all other functions as required and directed by Supervisor, in a willing and positive manner.

 Coordinates scheduled absences with co-workers to provide adequate coverage for department.



o Accuracy

 Maintains appropriate accuracy rate in accordance with the guidelines of Patient Access.

 Notifies physician offices of pre-certification/authorization issues in a timely manner to prevent unauthorized procedures from being completed.

 Completes 95% accuracy for pre-certifications/authorizations.



o Ability to produce workable ideas and techniques, willingness to attempt new approaches and perform job duties independently.

 Performs duties in an independent manner with minimal direct supervision.

 Can solve day to day problems within scope of practice and make decisions in a timely manner.

 Offers workable ideas, concepts and techniques to improve productivity.

 Willing to attempt new job duties, tasks, etc.

 Maintains regulatory requirements including all state, federal and Joint Commission regulations related to Patient Financial Services and, as appropriate, to the facility.

 Performs any other task as requested by Supervisor or Management in a willing and positive manner.

