Precertification Specialist

Mercyhealth Wisconsin and Illinois

Janesville (WI)

On-site

USD 24,000 - 36,000

Full time

14 days+

Application generator

Don’t send a generic resume — generate a resume and cover letter tailored to this exact role.

Get past ATS filters

Benefits offered by this job

Medical, Dental, Vision

Life & Disability Insurance

FSA/HSA Options

Paid time off

Parental and caregiver leave

Career advancement and educational opp

Tuition and certification reimburse

Job summary

Mercyhealth Wisconsin and Illinois is hiring for a Pre-Certification Specialist responsible for obtaining pre-certifications, verifying benefits, and coordinating with payors to ensure procedures are authorized before services. The role requires strong communication, detailed data gathering, and Epic knowledge.

Ideal candidates will have a high school diploma and at least one year of related healthcare experience; familiarity with payor requirements and documentation standards is essential.

Qualifications

High school diploma or equivalent preferred.
One year of pre-certifications, medical billing, registration, healthcare experience, or related education preferred.

Responsibilities

Identify all scheduled patients requiring pre-certification or pre-determination.
Contact insurance companies or employer groups to obtain pre-certifications and determine eligibility.
Obtain necessary clinical documentation for pre-certification.
Ensure authorizations are obtained and documented prior to date of service.

Skills

Excellent communication

Organizational skills

Problem solving

Computer experience

Epic knowledge

Independent worker

Education

High school diploma or equivalent

1 year pre-certifications/medical billing/healthcare experience

Tools

Epic

Job description

ESSENTIAL DUTIES AND RESPONSIBILITIES

Identify all scheduled patients requiring pre-certification or pre-determination through various systems.
Identify all relevant patient data elements and information from the various systems to acquire precertification.
Contacts insurance companies or employer groups to obtain pre-certifications, predeterminations, and determine eligibility and benefits for necessary services.
Make necessary contact to follow up if there are insurance issues in order to obtain financial resolution.
Obtain necessary clinical documentation to use in the pre-certification process.
Coordinates follow-up timely to ensure procedures are authorized and documented prior to the date of service while ensuring all payor requirements are met to ensure payment.
Communicates with designated Mercy Partners, Patient Financial Counselors regarding outcome of pre-certifications, benefits and patient financial responsibility.
Obtains insurance information to complete payor requirements.
Maintains current knowledge of payor payment provisions and regulations.
Keep current of ICD-9/ICD-10 and CPT coding requirements.
Ability to utilize computer software to complete pre-certification processes.
Meets department productivity and accuracy expectations.
Understands and follows patient confidentiality policies.
Ability to determine network status, eligibility, and coverage for patients to ensure reimbursement for services. Maintains current knowledge of payor payment provisions and regulations.
Communicate in a professional, respectful manner with provider offices regarding peer to peer information for follow-up ensuring authorizations can be obtained for procedures pended for medical review.
Follows documentation standards on all patient encounters on appropriate patient account utilizing notes. Ensures account is updated to accurately reflect the current status.
Ability to work independently with minimal supervision and be result oriented.
Provide training and mentoring
May be required to work alternate shifts, weekends and overtime during peak periods.
Participates in educational programs to meet mandatory requirements and identified needs with regard to position and personal growth.
Performs other duties as assigned.

EDUCATION AND/OR EXPERIENCE

High school diploma or equivalent preferred.
One year of pre-certifications, medical billing, registration, healthcare experience, or other business or healthcare related education preferred.

CERTIFICATION/LICENSURE

N/A

OTHER SKILLS AND ABILITIES

Excellent oral communication skills/organizational skills
Ability to handle stress and problem solve
Computer experience required
Knowledge of Epic preferred
Able to work independently

LEVEL OF SUPERVISION

Some independent judgment is required, but alternatives are limited by standard practices or procedures.

SUPERVISES

This position has no supervisory responsibility

PAY RANGE:

$17.57 - $26.36

Mercyhealth is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identify, national origin, disability, or protected veteran status.

Mercyhealth offers competitive pay and a comprehensive benefits package including:

Medical, Dental, Vision
Life & Disability Insurance
FSA/HSA Options
Generous, accruing paid time off
Paid Parental and caregiver leave
Career advancement and educational opportunities
Tuition and certification reimbursement
Certification Reimbursement
Well-being Programs
Employee Discounts
On-Demand Pay
Financial Education
Annual recognition/awards events
Partner appreciation days
Family entertainment/attractions discount
Community service/improvement opportunities

At Mercyhealth, we don’t simply hire people, we empower employee-partners who are passionate about making lives better. As an integrated health system, we deliver exceptional, coordinated across seven hospitals, 85 primary and specialty clinics, and a team of over 7,500 professionals serving northern Illinois and southern Wisconsin.

Mercyhealth has been nationally recognized for our commitment to our people and culture, including: