PreCert Specialist

Position Summary:  This position is the front line defense that the patients have precertification for procedures, drugs, radiology as well as one who enters into the computer all the patient information which forms the foundation of every transaction throughout the clinic and satellite offices.  Work is performed under the general direction of the Revenue Cycle Manager.

Essential Duties and Responsibilities:

1. Verify all demographic and insurance information on patients, including but not limited to co pays, deductibles, stop losses, guarantors, subscribers, precertification requirements, and in patient requirements. Update demographic and insurance information in a timely fashion.

1. Obtain and review Physician orders for medical necessity coverage requirements.

1. Research coverage criteria with insurance companies, medical literature, and compendiums to determine eligibility for services timely. Utilize multiple healthcare websites. Run computer generated reports for appointment schedules.

1. Communicate with all designated personnel eligibility issues in a timely fashion

1. Other Duties as Assigned: Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.

1. Attendance and the ability to get to work and follow the attendance policy is an essential element of this job

Qualifications / Experience:

Description The Pre-Certification Specialist I (Chemotherapy / Radiology) provides specialized assistance to our patients and clinical staff using their knowledge base of pre-certification requirements of insurance plans as well as provide excellent patient service. Requirements EDUCATION, CERTIFICATION, LICENSURE, REGISTRATION:

1. High school graduate or equivalent. EXPERIENCE, KNOWLEDGE, SKILLS and ABILITIES:
2. Minimum of two years’ experience working in healthcare insurance or medical clinic
3. Experience in a medical clinic or other healthcare environment with high patient volumes
4. Experience working with Microsoft Office applications
5. Experience utilizing multiple systems and websites; must include strong navigational skills using the Intranet as well as utilization of Internet sites.
6. Experience working with managed care, medical terminology, pre-cert processes, and insurance claims processing 6. Working knowledge and familiarity of coding (such as ICD9, ICD10, CPT, and HCPCS) in order to effortlessly process chemo pre-certification requests
7. Ability to handle high patient volumes daily
8. Excellent problem solving skills and be extremely detail oriented

Ability to demonstrate knowledge and experience with clinical coverage guidelines and medical policies.

Work Environment/Physical Demands/Travel:

1. Typical clinical environment with moderate noise level.
2. Ability to stand, walk, sit and use hand/wrist, talk, hear, see, and stoop or crouch for extended periods of time.
3. Ability to read and understand documents such as safety rules, operation and maintenance instructions, procedure manuals, correspondence. Ability to write routine reports and correspondence.  Ability to speak and present information in small groups of customers, suppliers or employees of the company.
4. Ability to add and subtract two digit numbers and to multiply and divide with 10’s and 100’s. Ability to perform these operations using units of US dollars, weight measurement, volume, and distance.
5. Ability to apply common sense understanding to carry out detailed written or oral instructions. Ability to deal with problems involving a few concrete variables in routine situations.
6. Ability to lift up to 10 lbs.
7. Some travel may be required.