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

at  Northeast Georgia Health System

Job Category:
Administrative & Clerical
Work Shift/Schedule:
8 Hr Evening - Morning
Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.
About the Role:
Job Summary
Under the supervision of the Utilization Review Manager, this position is responsible for ensuring the delivery of outstanding customer service in the process of obtaining pre-certification approvals from insurance companies (for both inpatients and outpatients), identifying insurance and/or patient responsibility, insurance verification, admission notifications, identifying approved days, follow up required, and providing financial counseling when appropriate.

Minimum Job Qualifications

• Licensure or other certifications: AAPC or AHIMA certification accepted
• Educational Requirements: High School Diploma or GED
• Minimum Experience: In lieu of CPC certification, will accept 5 years direct pre-certification experience.
• Other:

Preferred Job Qualifications

• Preferred Licensure or other certifications: CPC Certification
• Preferred Educational Requirements:
• Preferred Experience: One (1) year of direct pre-certification experience preferred with CPC certification.
• Other:

Knowledge, Skills and Abilities

• 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

Essential Tasks and 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.

Physical Demands

• Weight Lifted: Up to 20 lbs, Occasionally 0-30% of time
• Weight Carried: Up to 20 lbs, Occasionally 0-30% of time
• Vision: Moderate, Constantly 66-100% of time
• Kneeling/Stooping/Bending: Occasionally 0-30%
• Standing/Walking: Occasionally 0-30%
• Pushing/Pulling: Occasionally 0-30%
• Intensity of Work: Occasionally 0-30%
• Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals.
NGHS: Opportunities start here.
Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status

• 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