Insurance Precert Representative

WOOSTER COMMUNITY HOSPITAL JOB DESCRIPTION

Insurance Precert Representative

MAIN FUNCTION:

Protects hospital payments for inpatient admissions and outpatient services requiring precertification. Ensures all proper notifications of admissions have occurred. Ensures all scheduled outpatient services requiring prior authorization/precertification have the correct and appropriate authorizations prior to services being rendered.

RESPONSIBLE TO: The Director and Manager of Patient Access

MUST HAVE REQUIREMENTS:

Experience working in a physician’s office or hospital setting with third party payers to obtain authorization for hospital services

Proficient in medical terminology

Strong organizational skills and demonstrated ability to work independently.

Current computer or Meditech skills

Demonstrated effective interpersonal and oral communications skills

No written disciplinary action within the last 12 months.

PREFERRED ATTRIBUTES:

2 years previous experience in a physician office or hospital setting

Prior medical billing and/or coding knowledge

Post High School education in medical office skills

Ability to utilize internet and other technology

* Denotes ADA Essential

* Follows appropriate service standards

POSITION EXPECTATIONS:

* Receives notification of services/testing scheduled to be performed at the hospital

* Effectively navigates payer websites to verify insurance benefits and obtain necessary pre-certs per payer guidelines

* Contact third party payers when necessary to request authorization for services ordered

* Enters verification information in Meditech system and physician office EMR

* Accesses the physician’s EMR to obtain clinical information pertaining to the ordered service. Must be able to review the EMR to obtain prior testing results (ie, lab values, imaging results, etc)

* Initiates the precertification notification for all inpatient admissions

* Verifies completion of all needed pre-certs for outpatient procedures

* Communicates precertification denials to physician office and WCH scheduling

* Maintains a professional relationship with the physician’s and their office staff

* Keeps an organized record of precertification worklists

* Communicates effectively with other departments all information necessary to complete the precertification process

* Functions successfully in a team oriented work environment