Contacts insurance companies and other third party payers to determine pre-certification, pre-authorization and/or medical necessity requirements for complex outpatient hospital services, and specialized procedures (i.e. Recurring Visits, Surgeries, IR). Obtains pre-certification or pre-authorization prior to the scheduled service being performed.
Liaisons with physicians and physician office staff including peer to peer when needed to obtain additional demographic, insurance or clinical information. Provides clinical support to Patient Connection Center Authorization and Prep Associates or as needed.
1.Initiate a Peer to Peer with the Medical Director of the respective Payer, in order to provide supporting information that may obtain an authorization.
2.Uses benefits and order information on file to initiate and secure pre-authorizations in advance of the day of care.
3.Communicates with physicians, patients, and payers to secure and/or provide missing demographic, insurance, and/or clinical information to authorize service(s).
4.Documents all payer communications thoroughly, and communicated payer decisions in a timely manner.
5.Communicates with clinical staff and revenue cycle leadership.
6.Complies with HIPAA regulation and procedures at all times.
7.Handles oneself in a professional and courteous manner representing Piedmont when working with internal staff, patients, and payer representatives.
MINIMUM EDUCATION REQUIRED:
Graduate of a nursing program.
MINIMUM EXPERIENCE REQUIRED:
Two (2) years of related experience in healthcare with precertification/authorization experience.
MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW:
Current State of Georgia Registered Nurse license.
Three (3) years of previous related experience, preferably with precertification/authorization experience, preferred.
Bachelor's degree from a recognized college or university preferred.
Certification with Healthcare Financial Management Association or Certified Revenue Cycle Representative is preferred.
Prior Epic experience is desired.