Pre-Certification Specialist

Mercy Health System Harvard , IL 60033

Posted 2 months ago

JOB SUMMARY Verification/certification of patient care services to ensure financial reimbursement.

Responsible for insurance benefit verification and provision of clinical information for pre-certification for surgeries and other procedures and services as required by insurance companies.

Interpret medical record documentation for patient history, diagnosis, and treatment options to facilitate authorizations. Communicates effectively and professionally with many stakeholders. Complete necessary forms for insurance companies and initiates appropriate follow-up.# Process patient referrals to other specialties, both within Mercy Health System and to outside providers, if necessary.

Utilizes excellent customer service by demonstrating written and oral communication skills.# Documents thoroughly and according to department and health system expectations. Performs other duties as assigned. # ESSENTIAL DUTIES AND RESPONSIBILITIES # # Identify all patients requiring pre-certification or pre-authorization through various systems. Acquire pre-certification data elements from the Epic system.

Contacts insurance companies or employer groups to determine eligibility and benefits for necessary services. Make necessary contact to follow up if there are insurance issues in order to obtain financial resolution and payment on account. Obtain necessary clinical documentation to use in the pre-certification process.

Contact payor and communicate clinical information to obtain authorization for requested services. Timely documentation of referrals/authorizations/pre-certifications in appropriate systems. Coordinates follow-up to insure all payor requirements are met and payment is expected.

Obtains insurance information to complete payor requirements.# Maintains current knowledge of payor payment provisions and regulations. Keeps abreast of denials related to pre-certification and assist with appeal of denials. Keep current of ICD-9/ICD-10 and CPT coding requirements.

Ability to utilize computer software to complete pre-certification processes. Participates in educational programs to meet mandatory requirements and identified needs with regard to position and personal growth. Maintains logs and documents activity timely within patient accounting system. Understands and follows patient confidentiality policies. # AGE OF PATIENT POPULATION ######



All ages, including other physician offices, and other hospital/clinical personnel.



OCCUPATIONAL EXPOSURE OSHA Exposure Category C which means no employees in the specific job classification have occupational exposure. # COMPETENCIES To perform the job successfully, an individual should demonstrate the following competencies: Quality- Follows policies and procedures. Adapts to changes in the environment. Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality. Applies feedback to improve performance. Service

  • Responds promptly to requests for service and assistance.# Meets commitments. Abides by MHS confidentiality and security agreement.# Shows respect and sensitivity for cultural differences. Partnering

  • Supports organization#s goal and values. Exhibits objectivity and openness to other#s views.

    Gives and welcomes feedback. Contributes to building a positive team spirit. Generates suggestions for improving work. Cost

  • Conserves organization resources. Problem Solving- Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.

    Technical Skills- Assesses own strengths and weaknesses; Pursues training and development opportunities; Strives to continuously build knowledge and skills; Shares expertise with others. Interpersonal Skills- Focuses on resolving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control. Judgment- Displays willingness to make decisions; Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate people in decision-making process; Makes timely decisions.

    Planning/Organizing- Prioritizes and plans work activities; Uses time efficiently; Sets goals and objectives; Develops realistic action plans. Motivation- Sets and achieves challenging goals. Professionalism- Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration; Accepts responsibility for own actions; Follows through on commitments.

    Quantity- Meets productivity standards; Completes work in timely manner. Safety and Security- Observes safety and security procedures; Reports potentially unsafe conditions; Uses equipment and materials properly. Adaptability- Adapts to changes in the work environment; Manages competing demands; Changes approach or method to best fit the situation; Able to deal with frequent change, delays, or unexpected events.

    Attendance/Punctuality- Is consistently at work, on time, ready to work. Dependability- Follows instructions, responds to leadership direction; Takes responsibility for own actions; Keeps commitments. Initiative- Undertakes self-development activities; Looks for and takes advantage of opportunities. Innovation- Displays original thinking and creativity; Meets challenges with resourcefulness; Generates suggestions for improving work; Develops innovative approaches and ideas.

EDUCATION, TRAINING, # EXPERIENCE # High school graduate or GED required Knowledge of third party payor requirements Basic knowledge of medical terminology Basic knowledge of ICD-9, ICD-10, and CPT coding preferred #



ADDITIONAL REQUIREMENTS ###



Passing the Driver#s License Check and/or Credit Check (for those positions requiring). ###



Passing the WI Caregiver Background Check and/or IL Health Care Workers Background Check. Must be able to follow written/oral instructions. # OTHER SKILLS AND ABILITIES ####################



Excellent customer service and telephone etiquette Excellent oral communication skills/organizational skills Ability to handle stress and problem solve Computer experience required Knowledge of Epic desirable Able to work independently



Language Skills Ability to read and interpret documents such as emails

, insurance documents, guidelines, instructions, and procedure manuals. Ability to write routine reports and correspondence.

Ability to speak and communicate effectively to customers and other partners. # Mathematical Skills Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret basic graphs. # Reasoning Ability Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations. # Computer Skill To perform this job successfully, an individual should have knowledge of McKesson#s HBOC Star and PPP PLUS Database software, payor sites for claims and authorization statuses, and eligibility software, and Microsoft Office Suite (primarily Word and Excel).# Must be able to multitask and toggle between screens, document in different systems timely, thoroughly, and efficiently.




WORK ENVIRONMENT Occupational exposure is a Category C, which means employees in the specified job classification have no occupational exposures. The noise level in the work environment is usually moderate. #



INFORMATION ACCESS Partner may access patient care information needed to perform their job duties. Partner may access financial data. # WORK CONTACT GROUP Partners, physicians, patients/family, visitors, vendors, including other physician offices, and other hospital/clinical personnel.



SPECIAL PHYSICAL DEMANDS



The Special Physical Demands are considered essential job function of the position with or without accommodations. Medium work exerting 10 to 25 lbs of force or lifting occasionally.

While performing the duties of this job, the employee is frequently required to sit, handle, finger, feel, reach, talk and hear. The employee is occasionally required to stand, walk, stoop, kneel, crouch and crawl. Specific vision abilities required by this job include frequent close vision and ability to adjust focus and occasional distance vision.

Prolonged sitting. Manual dexterity needed to operate telephone and keyboard. ##



LEVEL OF SUPERVISION: Some independent judgment is required, but alternatives are limited by standard practices or procedures. # SUPERVISES This job has no supervisory responsibilities. # #

Full time Precertification Specialist position located at Mercy Woodstock Clinic. This position is responsible for verification/certification of patient care services to ensure financial reimbursement.

Responsible for insurance benefit verification and provision of clinical information for pre-certification for surgeries and other procedures and services as required by insurance companies.

Interprets medical record documentation for patient history, diagnosis and treatment options to facilitate authorizations.



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Pre-Certification Specialist

Mercy Health System