Precertification Rep- Stamford Diabetes & Endo

Responsible for functions and activities related to obtaining insurance precertification/authorization for procedures, surgeries and diagnostic services on behalf of the patient and the Practice, including, but not limited to, accurate and complete patient registration in the electronic scheduling and billing system, insurance verification and updates, contacting third party payers via phone, fax and internet to obtain necessary approvals and communicating results to the patient, physician and other staff. This position requires a working knowledge of Medicare, Medicaid and Commercial insurance plans, medical terminology and billing. It requires strong verbal and written communication, customer service and organizational skills.

• Performs timely insurance verification/eligibility processes utilizing the practice management system, automated electronic eligibility functionality, various reports, and third party payer websites and customer service telephone contacts related to ordered/scheduled procedures, surgeries and diagnostic testing.

• Ensures that all insurance, demographic and eligibility information is obtained and entered into the system in an accurate manner per established Practice policies and procedures. Communicates with patient to identify missing information and make corrections as needed.

• Contacts insurance companies on behalf of the Practice and the patient to initiate and complete the precertification/authorization process as required by the patient's insurance company for ordered procedures, surgeries and diagnostic testing.

• Coordinates with insurance companies, physicians and patients to provide all appropriate documentation required for the precertification/authorization of services including but not limited to the medical record, procedural (CPT) and diagnostic (ICD10) coding, and Letters Of Medical necessity per the established procedures of each insurance carrier and the Practice.

• Performs and documents tracking and follow up on all open precertification/authorization requests in a timely manner. Provides additional information to carriers as requested. Coordinates peer review requests from insurance carriers with the ordering physician.

• Notifies physician and other Practice staff and/or patient when services are not approved. Knows process and protocols for appealing precertification decisions and coordinates appropriate response as determined by the physician.

• Keeps records of all activities related to the precertification/ authorization process including but not limited to method of contact, dates of follow up, contacts and phone numbers and all reference numbers. Documents information given or received to support actions taken.

• Documents approval/denial of precertification/authorization for services in the electronic medical record per established policies and procedures. Scans appropriate documents to the patient's chart for reference.

• Develops and maintains a working knowledge of the procedures performed and ordered by the Practice. Has working knowledge of CPT and DX coding.

• Researches third party payer requirements and processes for precertification/authorization requirements pertaining to services provided by the Practice. Develops and maintains reference guides and resources related to processes. Communicates changes in authorization processes, insurance policies and billing requirements to appropriate Practice staff.

• Assists the Revenue Cycle Department in researching and resolving denied claims for precertification/authorization.

• Identifies al patients without third party financial benefits and directs them for financial counseling according to Financial Counseling and Revenue Cycle policies and procedures.

• Provides for high level customer service to internal and external customers. Has ability to explain and educate patients and staff regarding complicated insurance processes.

• Practices and adheres to Stamford Health's (SH) Code of Conduct, Stamford Health Medical Group's (SHMG) Standards for Service Excellence and organizational values of: Teamwork, Integrity, Compassion, Respect and Accountability.

• High School Diploma or General Education Development (GED) required. Clinical training a plus.

• 1 to 2 years of previous insurance verification, pre-certification/pre-authorization, medical billing, or other related experience in healthcare environment.

• High level of competency with computers, electronic medical records, the Internet, and computer software such as MS Office or equivalent is required.

• Knowledge of medical office operations, coding and billing, medical terminology and third party insurance processes is required.

• Demonstrated ability to prioritize and manage multiple tasks and demands given tight time constraints while ensuring a high degree of accuracy and attention to detail. Must be able to manage time efficiently with minimal supervision.

• Demonstrated ability to maintain confidentiality of all records per State, Federal and Practice laws, guidelines, policies and procedures.