Pre-Certification Specialist (Full-Time)

Responsible for the completion of pre-certification, prior authorization and notification for third party and government payers for all pre-scheduled elective inpatient and outpatient examination and procedures requiring preauthorization. May provide back-up pre-certification/prior authorization resources for other departments as needed. Coordinates/educates physicians, nursing staff and other health care providers on the pre-certification process and requirements. Tracks, documents, and monitors pre-certifications. Implements checks and balance systems to ensure compliance. Essential Job Functions

• Supports and practices the mission and philosophy of Billings Clinic and Radiology Department.
• Coordinates pre-certification process with provider offices to ensure target goal of 98% of pre-scheduled elective inpatient and outpatient procedures are pre-authorized.
• Documents and maintains patient specific pre-certification/authorization data within the required information systems. Compiles, documents, and tracks monthly pre-certifications using established procedures.
• Keeps undated list. Ensures correct patient status when pre-certifying.
• Reviews CPT-4 codes of required pre-certification and/or authorizations; ensuring Passport pre-certification process is also met.
• Reports denials and/or delays in the pre-certification process to physicians/other health care providers and the patient. May provide information to the patient on the appropriate appeal procedures for denials.
• Responsible for coordinating resolution of varied problem situations and performing necessary investigation and research to resolve pre-certification problems.
• Reports non-compliance issues and/or needs for program expansion to Manager.
• Works closely with Medical Staff, Payer Relations and Patient Financial Services to coordinate needed pre-certification authorizations for in-network services.
• Tracks and verifies receipt of pre-certification authorizations has been received either verbally or written. Communicates status to providers and patients as needed.
• Develops and maintains collaborative working relationships with payers and health care providers.
• Reviews, updates and standardizes forms and processes as needed
• Participates in interdepartmental meetings to coordinate efforts, work through processes, and foster communication.
• Develops and maintains reference manuals that outline the individual payer requirements as it relates to pre-certification and pre-authorization needs. Responsible for the integrity and accuracy of the payer data
• Assists patients/family members with status of pre-certification or re-certification information.
• Identifies needs and sets goals for own growth and development; meets all mandatory system/department requirements. Maintains knowledge of current trends and developments as it relates to the pre-certification process.
• Maintains competency in all organizational, departmental and outside agency environmental, employee or patient safety standards relevant to job performance.
• Performs other duties as assigned or needed to meet the needs of the department/organization.

Minimum Qualifications

Education

• High school graduate or equivalent Experience
• One (1) year of medical insurance claims experience through patient accounts billing or claims adjudication