Patient Services, Pre Registration

A Day in the Life: The Pre-Certification Specialist is responsible for creating, tracking, and completing medical treatment pre-certification requests for various insurances for patients who seek medical services. This role is required to utilize all available resources to verify eligibility, benefit levels, and patient copayment/coinsurance responsibilities.

• Verify and validate patients medical plan benefits and requirements according to their specific medical policy, to ensure necessary procedures are covered by an individual’s provider and maximum payment for services rendered, as well as complete registrations for upcoming visits.
• Submit prior authorizations to insurances in timely matter via payer specific portals and vendors.
• Ensures all pertinent medical documentation is accurate and present prior to authorization submission to minimize financial risk.
• Follows up with insurance companies to ensure documentation has been received, the current status or to be informed of any action needed in order to obtain the authorization approval.
• Communicates any authorization denials to the appropriate staff.
• Handles any discrepancies, errors, or omissions of authorization denials and files appeals when necessary for overturn of adverse decision.
• Clearly document all communication and prior authorization documentation, in standardized documentation requirements, and save in Electronic Health Record (EHR) as appropriate.
• Obtains timely authorization of all patients requiring pre-certification and is accountable for conversion percentage and results.
• Follow through with payer correspondence and requests for more information related to each authorization and appeal submission.
• Gather required/additional supporting documentation and information, including state protocols, physician or hospital medical records, state or federal statutes, patient, or physician letters of medical necessity, etc.
• Communicate with physician offices, their staff/clinical contacts, and patients on the progress of their prior authorization or internal appeal requests.
• Educate patients on coordination of coverage and other insurance issues, as well as securing payment of patient’s financial liability
• Build and maintain professional, cooperative relationships with all departments that have direct or indirect impact on obtaining authorizations.
• Clearly document all communications and contacts with payers, physicians, and families in standardized documentation requirements including proper format. Communicate effectively, timely and professionally in writing and verbally.

What We're Looking For:

• Ability to work in a production driven call-center environment
• Must demonstrate problem-solving abilities and high attention to detail.
• Computer/tech savvy with experience navigating between multiple systems simultaneously
• Must have MS Office Experience, fast and accurate typing skills
• Extensive multitasking ability
• Strong written and verbal communication skills

Requirements:

• High school diploma or GED
• Extensive experience in medical pre-certifications and pre-registrations
• Two years in a professional, customer service-driven environment preferred, completion of related medical certification program
• Telephone/call center experience preferred
• 1 year of customer service experience