Precertification Specialist 1

Mercyhealth Wisconsin and Illinois; United States; Remote; USD 24,000 - 39,000; Full time

Benefits offered by this job

Medical, Dental, Vision

Life & Disability Insurance

FSA/HSA Options

Paid time off

Parental leave

Tuition reimbursement

Certification reimbursement

Well-being programs

Employee discounts

On-demand pay

Job summary

Mercyhealth is seeking a Remote Full-Time Pre-Certification Specialist to identify patients needing pre-certification, verify eligibility, obtain documentation, and secure authorizations prior to service date.

You will communicate with insurance companies and provider offices, ensure payor requirements are met, maintain confidentiality, and stay current with ICD-9/ICD-10 and CPT coding. Training and mentoring may be provided.

Qualifications

• High school diploma or equivalent preferred.
• One year of pre-certifications, medical billing, registration, healthcare experience, or other related education preferred.
• Excellent communication and organizational skills; ability to handle stress.
• Knowledge of payer requirements; ICD-9/ICD-10 and CPT coding knowledge preferred.
• Ability to work independently.

Responsibilities

• Identify patients requiring pre-certification or pre-determination through various systems.
• Obtain necessary clinical documentation to use in the pre-certification process.
• Contact insurance companies or employer groups to obtain pre-certifications and determine eligibility and benefits.
• Follow up on insurance issues to obtain financial resolution.
• Ensure procedures are authorized and documented prior to the date of service.
• Communicate with Mercy Partners and Patient Financial Counselors regarding outcomes.

Skills

Excellent oral communication

Organizational skills

Stress management

Computer experience

Independence

Epic knowledge

Education

High school diploma or equivalent

Tools

Epic software

Job description

OVERVIEW:

Responsible for identifying patients requiring pre-certification or pre-determination, verifying insurance eligibility and benefits, obtaining necessary clinical documentation, and securing authorizations to ensure procedures are approved before the date of service. Maintains accurate patient account documentation, communicates with insurance companies, provider offices, and financial counselors to resolve coverage issues and support reimbursement while ensuring compliance with payer requirements and patient confidentiality policies. Demonstrates strong organizational, communication, and problem-solving skills while meeting productivity and accuracy standards, providing training and mentoring, and maintaining current knowledge of insurance regulations and coding requirements.

SCHEDULE:

Remote Full-Time, 40 hours per week.

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 - $27.97

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:

• #1 in the nation on AARP’s Best Employers for Workers Over 50
• One of Working Mother magazine’s 100 Best Companies for Working Mothers
• A Top 50 Company and Top 10 Nonprofit for Executive Women