Pre-Certification Specialist

Charleston Area Medical Center

Hurricane (WV)

On-site

USD 42,000 - 64,000

Full time

2 days ago

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Job summary

Charleston Area Medical Center is seeking an Administrative/Clerical professional to manage pre-certification and referrals for returning and new patients, ensuring complete charts and accurate scheduling of tests and surgeries.

You will review insurance requirements, communicate with Medicare and other carriers, and perform clerical duties including correspondence with patients and providers. This role supports front desk and medical assistant functions as needed.

Qualifications

High school diploma or GED required.
No certification or license required.
Experience in administrative/clerical support preferred.

Responsibilities

Review charts daily to determine pre-certification or referrals required.
Review patient insurance to determine medical necessity for treatments.
Communicate with Medicare and other insurers to obtain necessary data.
Draft letters to patients, insurers and physicians as needed.
Schedule surgeries and coordinate information with involved parties.
Coordinate referrals to other physicians after review of results.
Create new patient accounts in billing software and forward data to the chart.
Maintain current knowledge of ICD-10, CPT and HCPCS codes.
Cross-train for front desk and medical assistant tasks.
Schedule procedures and handle funds collection and deposits.

Skills

Customer service

Communication

Attention to detail

Education

High School Diploma or GED

Job description

Job Summary

To ensure procurement of accurate pre-certification authorization/referral for applicable returning and new patients as well as review and completion of accurate, complete patient charts. Scheduling of multiple physician ordered tests, exams and surgeries where applicable.

Responsibilities

Daily review of charts to determine if pre-certification/pre-authorization or referrals are needed.
Review specific patient insurance info to determine medical necessity requirements for specific treatments.
Correspond with Medicare and various insurance companies to facilitate obtaining pertinent data on compliance, authorizations, verifications, progress notes, medical necessity guidelines and precertification and pre-authorization requirements.
Perform clerical duties as necessary, including composing letters to patients, insurance carriers and referring physicians regarding any issues.
Per physician order, schedule patient surgery and communicate all necessary information to the appropriate parties.
Make subsequent referrals to other physicians per physician review of test/scan results.
Establish new patient account in billing software upon receiving referral from physician. Forward all applicable info to appropriate personnel for inclusion in the medical chart.
Maintain continuing education treatment trends, current medical terminology used in pre-certification, and ICD-10, CPT and HCPCS codes.
Cross train for front desk and medical assistant roles. Provide backup as needed.
Schedule all procedures, collect, apply and deposit all funds.

Knowledge, Skills & Abilities

Patient Group Knowledge (Only applies to positions with direct patient contact)

The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment or care as defined by the department's identified patient ages. Specifically the employee must be able to demonstrate competency in: 1) ability to obtain and interpret information in terms of patient needs; 2) knowledge of growth and development; and 3) understanding of the range of treatment needed by the patients.

Common Duties and Responsibilities

Maintain and document all applicable required education.
Demonstrate positive customer service and co-worker relations.
Comply with the company's attendance policy.
Participate in the continuous, quality improvement activities of the department and institution.
Perform work in a cost effective manner.
Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations.
Perform work in alignment with the overall mission and strategic plan of the organization.
Follow organizational and departmental policies and procedures, as applicable.
Perform related duties as assigned.

Education