Precertification Specialist

Centers for Pain Control; Valparaiso (IN); On-site; USD 42,000 - 54,000; Full time

Job summary

Centers for Pain Control seeks a Precertification Specialist to manage precertifications, prior authorizations, and payer communications for outpatient procedures. You will extract medical information, verify eligibility, and ensure timely approvals.

The role requires experience with health insurance verifications, coding knowledge, and strong communication skills to navigate payer requirements and improve revenue cycle efficiency.

Qualifications

• Experience with health insurance verification, authorizations or referrals preferred.
• Knowledge of CPT, ICD-10-CM and HCPCS coding guidelines.
• Strong communication and organizational skills with attention to detail.

Responsibilities

• Prioritize and process incoming authorization requests and orders.
• Review clinical documentation to extract information supporting medical necessity.
• Obtain patient benefit and eligibility status for pending procedures.
• Communicate with payers and utilization management for favorable outcomes.
• Appeal denied authorizations when warranted and initiate peer reviews.

Skills

Electronic Medical Record

Typing

Internet navigation

Office equipment knowledge

Multi-line phone system

Medical terminology

CPT/ICD-10-CM/HCPCS coding

Communication

Organization

Tools

EMR software

Job description

PURPOSE:The Precertification Specialist is responsible for the completion of precertification, prior authorization and notification for third party and government payers for all scheduled outpatient procedures and diagnostic testing. The Precertification Specialist is responsible for communicating with insurance companies, clinic staff, outside physician offices, facilities and patients to ensure authorizations are obtained in a timely manner.ACCOUNTABILITIES AND JOB ACTIVITIES:Prioritize and process incoming authorization requests/ordersReview clinical documentation to extract pertinent information which supports medical necessityObtain patient benefit and eligibility status for pending proceduresCommunicate effectively with payers and third party utilization management companies to achieve positive outcomesIdentify payer trends and provides feedback to the Billing Team Supervisor and providersAppeal denied authorizations when warrantedInitiate peer to peer reviews and prepares documentation packets for the providerMaintain understanding of payer medical policies and guidelinesManage work queues, emails and phone messages timely and effectivelyDevelop and maintain personal and professional skillsAttend all mandatory staff meetings per year unless excused as evidenced by documentationAttend mandatory in-services and a minimum of two pertinent in-services per year as documentedActively participate in performance improvement activities as observed or documentedEstablish realistic professional goals as evidenced by the annual performance evaluationActively keep abreast of departmental and organizational activitiesDemonstrate flexibility in response to unexpected change in workload or situations as observedServe on committees and/or participates in changes of policy and procedures that affect the revenue cycleAssist in the orientation of new personnel as directedSupport the mission and goals of the company as observedAddress all emails within 24 hours as documentedPerform other duties as requiredDemonstrate safe and cost-effective practiceConsistently adhere to OSHA bloodborne pathogen guidelines; apply universal precautions per company standards as observedConsistently utilize proper body mechanics as observedAccurately complete incident reports within the shift of occurrence and immediately communicates critical incidents to the appropriate person per the organizational chartConsistently allocate resources to reduce waste and minimize costs as observedConsistently complete assigned duties within stated shifts in a timely manner as observed and documentedBEHAVIORAL EXPECTATIONSStrive for excellenceSet challenging goalsProduce quality work in a timely fashionMaintain current knowledge and skillParticipate in quality and process improvement effortsKeep the work area clean, safe and secureAct FlexiblyAdapt to changeSee the value of different opinions and new ideasChange plans and objectives given new direction or prioritiesHandle stressful situations effectivelyMeet Customer NeedsMeet internal and external customers’ needsFind new ways of satisfying customersParticipate in service improvements effortsListen and respond to customersTreat customers with compassion and respectWork as a TeamWork as a team playerPitch in to help those in needCommunicate with others appropriatelyListen and respond to othersHandle conflict situations effectivelyFoster trust and respect within the teamParticipate in committees and task forcesFoster Diversity in the WorkforceTreat all associates and customers with respect, integrity and dignity regardless of background, race, age, gender, gender identity, sexual orientation, religion or disabilityTreat all associates and customers fairlyBe Self-directedTake initiative and responsibility for actionsIdentify own learning needs and create/implement Learning PlansPerform duties according to policies and proceduresDemonstrate ethical behaviorsMaintain confidentiality of informationMaintain licenses and certifications as appropriateFulfill operating unit/clinical competenciesUse equipment/resources responsiblyYou must refer to upper management for approval or final disposition on the followingChange in procedureDifficult patient situationsAny situation you are unsure ofJOB SCOPE AND WORK ENVIRONMENT:This position is subject to:Confidential informationExtended time sitting at a desk, utilizing a keyboard and multiple monitorsHigh stress environment due to turnaround requirementsDaily hours are subject to change on a daily basis due to schedulePatient Privacy HIPAAProtection of patient privacyPatient records and EMR are for treatment use onlyThe statements in this job description are intended to describe the essential nature and level of work performed by employees assigned to this job. They are not intended to be an exhaustive list of all responsibilities, duties and skills required of personnel so classified.JOB REQUIREMENTSCOMPETENT LEVEL QUALIFICATIONSMINIMUM LEVEL QUALIFICATIONSSKILLS(Typing and special machinery)-Knowledge of Electronic Medical Record-Good typing skills-Good internet navigation skills-Knowledge of instrumentation used in office (fax, credit card, copy)-Knowledge of multi-line phone system-Knowledge of medical terminology with a strong focus on the vascular, spine and skeletal system-Knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation, coding, and billing, with demonstrated ability to interpret such guidelines-advanced knowledge and skill in CPT, ICD-10-CM and HCPCS code assignment.-Strong communication and organizational skillsEDUCATION AND EXPERIENCE (Degrees, years in profession)-Previous hospital/ambulatory surgery center, or physician billing experience preferred-Minimum of 2 years experience working with health insurance verification, insurance authorizations, or specialist referralsCERTIFICATIONSN/AN/ASpecial Job Characteristics-Fast paced work environment with established time constraints-Must be able to work overtime when required-Must be able to multitask while maintaining accuracy-Must work well with othersOTHER REQUIREMENTS:Knowledge of common safety hazards and precautions to establish a safe work environmentMust be able to act calmly and effectively in busy, stressful or emergency situationsAbility to communicate effectively in person, by phone and in writingRequires adherence to all policies and procedures, including standards for safety, attendance, punctuality and personal appearanceThis position must be willing to do any additional tasks as assigned by managementPHYSICAL REQUIREMENTS:HEARING: Adequate to perform job duties in person and over the telephone.SPEAKING: Must be able to communicate clearly to patients & staff in person and over the telephone.VISION: Requires eyesight correctable to 20/20 to operate equipment and read information from printed sources and computer screens.OTHER: Requires frequent lifting and carrying items weighing up to 50 pounds unassisted, including assisting patients when required. Adequate physical ability to be present where needed.Requires frequent bending, reaching, repetitive hand movements, standing, walking, squatting and sitting, with some heavy lifting, pushing and pulling exerted regularly throughout a regular work shift. Requires exposure to communicable diseases, bodily fluids, medicinal preparations and other conditions common to a clinic environment.The above is intended to describe the general content and requirements for the performance for this position. It is not to be construed as an exhaustive statement of duties, responsibilitiesor requirements. I have read the job description and understand the functions and objectives of the position at this company. This position must be willing to do any additional assignment by management.