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Northeast Georgia Health System · 7 hours ago

Pre-Certification Specialist - Mon - Fri 9:00am - 5:30pm

Fruitville, FL

Full-time

Onsite

Entry Level

1+ years exp

Northeast Georgia Health System is rooted in a foundation of improving the health of our communities. The Pre-Certification Specialist is responsible for ensuring outstanding customer service in obtaining pre-certification approvals from insurance companies and managing patient insurance verification and financial counseling.

AssociationCommunitiesFitnessHealth Care

Responsibilities

Responsible for ensuring all scheduled and non-scheduled inpatient and outpatient accounts are pre-authorized either in advance or on the day of the notification of admission (following guidelines set forth by the organization and payers)

Provides and interprets clinical information submitted from the Physician, emphasizing the medical justification for a procedure, in order for completion of the pre-certification process

Works in conjunction with Physician offices, Case Management, Utilization Review, and patients to obtain supporting clinical data for the payer in order to obtain a pre-authorization

Obtains complete and accurate insurance information and completes verification of the patient's eligibility for both inpatient and outpatient hospital visits

Acts as liaison and point of contact for/between clinical staff, ancillary departments, patients, referring Physician's office, and insurance payers to inform of authorization delays/denials

Collaborates with Utilization Review nurses to ensure authorization for services is obtained and fully documented in the patient account

Ensures thorough documentation in the patient account of verification and authorization activities

Communicates with Physician office and payer to initiate and mediate Physician to Physician reviews

Understands and retains knowledge of payer requirements in relation to procedure vs. plan type and demonstrates the ability to make informed decisions as to when a pre-authorization is needed

Responsible for the accurate and timely documentation of the pre-certification into the appropriate account

Collaborates with the appeals department to provide all related information to overturn denied claims

Helps monitor insurance authorization issues to identify trends and participates in process improvement initiatives

Expected to answer, manage, and satisfy the customer during all incoming calls as appropriate to their specialty, and to meet department assigned goals relating to outbound calls, average speed to answer, max delays, AUX times, abandonment rate, and ACD time. In addition, expected to meet all customer service standards as set forth by the NGHS STARS standards

Performs any and all related job duties as assigned; may have additional department specific duties assigned as deemed necessary by management

Expected to meet all goals set by department management to include, but not limited to; productivity, accuracy, collections, and customer satisfaction

Qualification

AAPCAHIMA certificationCPC CertificationPre-certification experienceMedical terminologyInsurance guidelines knowledgeManage changeProblem solving skillsCommunication skillsOrganizational skillsWork independently

Required

AAPC or AHIMA certification accepted

High School Diploma or GED

Ability to work independently, emotionally mature, and able to function effectively under stress

Excellent problem solving and analytical skills

Excellent written and oral communication skills

Ability to prioritize, organize, and coordinate daily work load

Working knowledge of Protected Health Information

Ability to manage change

Extensive knowledge of medical terminology

Must possess detailed understanding and knowledge of insurance guideline and protocols, the components of full verification, and payer information / requirements