Patient Referral Assistant

MyMichigan Health; Alpena (MI); On-site; USD 42,000 - 64,000; Full time

Job summary

MyMichigan Health is seeking a Pre-certification/Denials Specialist to obtain prior authorizations for procedural orders and communicate with clinic staff, providers and scheduling. The role serves as a liaison with third-party insurers to stay current on referral procedures and manages denials and appeals as needed.

The ideal candidate has 2–4 years of medical office experience, strong knowledge of payer policies, and solid communication skills.

Qualifications

• Two to four years medical office experience with knowledge in payer medical policy guidelines.
• Excellent interpersonal/customer relations skills and ability to work independently.
• Advanced medical terminology, knowledge of obtaining prior authorizations, ICD9/ICD10, CPT coding.
• Experience within physician practice and knowledge of third payer rules, and medical record charting/documentation experience.
• Clinical experience preferred.
• Strong written and verbal communication skills.
• Proficient computer user; experienced in Windows, Word Processing, and medical practice software.

Responsibilities

• Completes prior authorizations related to Pain Management procedures; collaborates with providers and staff to finalize third party referrals.
• Reviews chart documentation to ensure policy guidelines, prioritizes requests by urgency, obtains authorization via payer websites or phone and follows up until complete.
• Maintains payer files with up-to-date requirements, initiates appeals for denials, responds to clinic questions, and confirms CPT/ICD codes in procedures orders.

Skills

Medical office experience

Payer policy knowledge

Interpersonal skills

Medical terminology

ICD-9/ICD-10 coding

CPT coding

EPIC EMR experience

Windows proficiency

Communication skills

Education

High School Diploma or GED

Tools

EPIC EMR

Microsoft Word

Job description

Summary

The Pre-certification/Denials Specialist is responsible for obtaining prior authorizations for all procedural orders by successfully completing the authorization process with all government and commercial payers. They will obtain and communicate via the electronic medical record to clinic personnel, providers, and hospital scheduling department.The position will be a primary liaison with third party/managed care insurers to stay informed of the latest changes, developments with pre-authorization referral procedures. This position will be responsible for the review and follow up of all pre-authorization denials. Position is productivity driven and will be monitored for performance measurements.

Responsibilities

• (40%)* Completes prior authorizations related to Pain Management procedures and medications. Works with providers, office staff & outside sources to complete third party referral authorizations accurately and timely.
• (30%)* Responsibilities will include reviewing chart documentation (EPIC EMR experience preferred) to ensure patient meets medical policy guidelines, prioritize incoming authorization requests according to urgency, obtain authorization via payer website or phone and follow up regularly on pending cases until complete.
• (30%)* Position will maintain individual payer files to include up to date requirements needed to successfully obtain authorizations, initiate appeals for denied authorizations, respond to clinic questions regarding payer medical policy guidelines, and confirm accuracy of CPT codes and ICD-10 diagnoses in procedure orders.

OTHER DUTIES AND RESPONSIBILITIES:

Ability to handle multiple tasks and stressful situations.

Must be able to communicate verbally in person, on the phone and in writing. Frequently position requires regular public contact, decision making and exposure to stress.

MyMichigan Health is a technology driven organization and employees need to demonstrate competency in Microsoft Windows. An employee may be required to participate in further learning opportunities.

Certifications and Licensures

N/A

Required Education

High School Diploma or GED

Other Information

EXPERIENCE, TRAINING AND SKILLS:

Two to four years medical office experience with k knowledge in payer medical policy guidelines.

Excellent interpersonal/customer relations skills and be able to work independently required

Advanced medical terminology, knowledge of obtaining prior authorizations, ICD9/ICD10, CPT coding.

Experience within physician practice and knowledge of third payer rules, and medical record charting/documentation experience required.

Clinical experience preferred.

Established written and verbal communication skills, good organization and prioritization skills.

Must be a proficient computer user; experienced in Windows, Word Processing, and medical practice software and possess Medic Computer knowledge. Experience in database application and skills preferred.

PHYSICAL/MENTAL REQUIREMENTS AND TYPICAL WORKING CONDITIONS:

Exposure to stressful situations, including those involving public contact, as well as, trauma, grief and death.

Able to wear personal protective equipment that includes latex materials or appropriate substitute if required for your position.

Is able to move freely about facility with or without an assisted device and must be able to perform the functions of the job as outlined in the job description.

Overall vision and hearing is necessary with or without assisted device(s).

Frequently required to sit/stand/walk for long periods of time. May require frequent postural changes such as stooping, kneeling or crouching.

Some exposure to blood borne pathogens and other potentially infectious material. Must follow MyMichigan Health bloodborne pathogen and TB testing as required.

Ability to handle multiple tasks, get along with others, work independently, regular and predictable attendance and ability to stay awake.

Overall dexterity is required including handling, reaching, grasping, fingering and feeling. May require repetition of these movements on a regular to frequent basis.

Physical Demand Level: Sedentary. Must be able to occasionally (0-33% of the workday) lift or carry 0-10 lbs.