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Pre-Certification Specialist
2 months ago
To ensure the procurement of accurate pre-certification authorization/referral for applicable returning and new patients, as well as the review and completion of accurate, complete patient charts. Scheduling of multiple physician-ordered tests, exams, and surgeries where applicable.
Key Responsibilities- Daily review of charts to determine if pre-certification/pre-authorization or referrals are needed.
- Review specific patient insurance information to determine medical necessity requirements for specific treatments.
- Correspond with Medicare and various insurance companies to facilitate obtaining pertinent data on compliance, authorizations, verifications, progress notes, medical necessity guidelines, and pre-certification and pre-authorization requirements.
- Perform clerical duties as necessary, including composing letters to patients, insurance carriers, and referring physicians regarding any issues.
- Per physician order, schedule patient surgery and communicate all necessary information to the appropriate parties.
- Make subsequent referrals to other physicians per physician review of test/scan results.
- Establish new patient account in billing software upon receiving referral from physician. Forward all applicable information to appropriate personnel for inclusion in the medical chart.
- Maintain continuing education on treatment trends, current medical terminology used in pre-certification, and ICD-10, CPT, and HCPCS codes.
- Cross-train for front desk and medical assistant roles. Provide backup as needed.
- Schedule all procedures, collect, apply, and deposit all funds.
- Patient Group Knowledge (Only applies to positions with direct patient contact): The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment, or care as defined by the department's identified patient ages.
- Common Duties and Responsibilities (Essential duties common to all positions): 1. Maintain and document all applicable required education. 2. Demonstrate positive customer service and co-worker relations. 3. Comply with the company's attendance policy. 4. Participate in the continuous, quality improvement activities of the department and institution. 5. Perform work in a cost-effective manner. 6. Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations. 7. Perform work in alignment with the overall mission and strategic plan of the organization. 8. Follow organizational and departmental policies and procedures, as applicable. 9. Perform related duties as assigned.
- High School Diploma or GED
- No Certification, Competency, or License Required
