Precertification Coordinator, Full-Time, Days
2 weeks ago
Inspire health. Serve with compassion. Be the difference.
Job Summary
Responsible for the financial and clinical aspects of all referrals made to the program, including logging all referrals, collecting and verifying pertinent demographic and financial data as well as obtaining pre-certifications and authorizations for new and ongoing treatment. Interacts regularly with internal customers, third party payors and outside referral sources. Performs complex tasks using Microsoft Office applications. Responsible for compliance issues related to medical necessity and coding. Accountabilities* Processes and tracks incoming referrals. Logs all incoming referrals according to program guidelines. Obtains medical records to support referrals. Prepares referral with clinical and financial information for submission to Program Director. Coordinates patient assignment to case management and communicates with referral source as to the status of the referral. 25%
* Advocates for and secures coverage for all patients referred for services. Explains the unique aspects of the program to insurance representatives and provides the program description to all third party payors in order to increase accuracy of pre-certification determinations and financial information. Verifies insurance benefits to include all possible services and CPT codes billed by program and need for pre-certification or pre-authorization for treatment. Pursues any needed clarification of insurance benefits prior to scheduling of patients.
Obtains staffing requirements related to third party payors based on requirements for in-network providers and communicates information to case management to maximize reimbursement.
Maintains public relations with patients and third party payors, including insurance case managers, in accordance with GHS Service Excellence standards. 25%* Collects and verifies pertinent patient demographics and financial data on all new patient referrals with physician offices and other referral sources. Communicates with referral source to obtain additional information required for completing referral, including ICD-9 coding as well as ascertaining appropriate medical records to determine eligibility for program admission. 15%
* Collects and verifies pertinent patient demographics and financial data on all ongoing patients under continuing treatment. Obtains continuing authorizations for treatment under 3rd party payor guidelines and time frames and completes required documentation. Facilitates documentation needs by third party payors for continuing treatment. Provides initial advocacy and informational needs for recurring treatment with third party payors and notifies case management of additional contact required. 15%
* Performs compliance functions related to coding, billing, demographics and and payor source. Facilitates ICD-9 codes on initial orders. Coordinates supplemental ICD-9 coding to support medical necessity of treatment and communicates to GHS Medical Information Department in a timely manner. Monitors timeliness of physician continuing orders for treatment for all program and PRN patients. 10%
* Performs multiple business office functions using MS Office applications. Coordinates patient scheduling process, updates waiting lists, prepares written communication to physicians regarding referrals and performs database entry.
10% Supervisory/Management Responsibilities This is a non-management job that will report to a supervisor, manager, director or executive. Minimum EducationHigh School diploma or equivalent
Minimum Experience2 years- Insurance, billing, collections, customer service and/or healthcare business office.
Other Required ExperienceKnowledge of ICD-10 and CPT coding conventions- Preferred
Work Shift
Day (United States of America)Location
North Greenville Med CampusFacility
1027 North Greenville Long-Term Acute Care HospitalDepartment
10279079 Post-Acute Bed PlacementShare your talent with us Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.
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