HOW TO APPLY

A cover letter is required for consideration for this position and should be attached as the first page of your resume. The cover letter should address your specific interest in the position and outline skills and experience that directly relate to this position.

JOB SUMMARY

The Precertification staff perform clinical reviews on all scheduled short stay and inpatient admissions to the hospital. The precertification review process includes the application of diagnosis and procedure codes and the interpretation and extraction of pertinent clinical documentation to support medical necessity criteria and level of care determinations. The precert team obtains authorizations for services based on our level of care decisions, preliminary coding and payer requirements. The Precertification staff work closely with a variety of internal and external customer including but not limited to clinical areas, medical providers, insurance companies, admitting, case management and revenue cycle.

REQUIRED QUALIFICATIONS*

• An Associate’s degree in Health Information Technology, Healthcare Administration, or other healthcare related field and/or current Professional Coding Certification (CPC) with 2-3 years of healthcare experience is necessary.
• Experience working with insurance companies and third party payers is required.
• Ability to assess and extract appropriate clinical information from a patient’s medical record is necessary.
• Strong written and interpersonal communication skills, problem solving, decision making and negotiation skills are required.
• Must have demonstrated ability to work well with physicians, other healthcare providers and co-workers.
• Excellent computer application skills are required.
• Strong dedication to customer service, ability to be flexible and work within a team-focused, participative management framework is required.

DESIRED QUALIFICATIONS*

• A Bachelor’s Degree and prior experience working in Precertification, Coding, Health Information Management or Utilization Review is strongly desired.
• Knowledge of Interqual and/or MCG criteria and government insurance regulations is recommended.
• Understanding and ability to interpret medical terminology and insurance benefit information is preferred.

• Coordinate and conduct pre-admission reviews for all scheduled and urgent (non-same day) admissions and short stays. Determine appropriate level of care based upon clinical review, medical necessity criteria and institutional patient placement guidelines.
• Assign ICD-10 and CPT codes for planned procedures/treatment and provide to payers as required. Utilize preliminary codes to identify procedures requiring inpatient status or procedural authorizations to assure accurate reimbursement.
• Evaluate all patient payment sources, verify insurance eligibility, collect insurance benefit information and determine insurance referral and authorization requirements based on level of care determination.
• Complete all aspects of the pre-authorization process and negotiate the appropriate level of care for patient services within required timeframes. Extract pertinent clinical information from the electronic health record and provide to payers utilizing payer specific communication protocols.
• Initiate interventions when criteria is not met and initiate follow up actions as needed. Coordinate peer to peer reviews between attending, physician advisors and medical directors at the insurance company when appropriate. Coordinate, initiate and follow through on preadmission appeals on behalf of Michigan Medicine, the providers and patients until case approved or all appeal options are exhausted.
• Identify and communicate issues related to level of care determinations and prior authorizations to the appropriate clinical areas. Refer potential patient liabilities to the patient business services areas per established guidelines.
• Conduct admission and discharge reviews for the Obstetric-Labor and Delivery population of patients admitted to the hospital. Obtain inpatient authorizations as needed and follow the patient encounter until mom and well-baby are discharged, ensuring all payer requirements are met. Maintain workqueues and patient lists, update the patient class as appropriate and follow-up on OB admission claims issues until resolution when needed.
• Clearly and thoroughly document all actions, contacts, outcomes and interventions to assure appropriate payment of claims.
• Provide and discuss authorization status information to patients when appropriate
• Inform physicians and clinical staff on the aspects of medical necessity criteria and payer requirements.
• Obtain retro authorizations on billed and rejected claims and denied procedure codes for facility and professional services. Initiate appropriate follow-up actions in response to information obtained and document outcomes for appeals as needed.
• Attend and participate in operational meetings, utilizing LEAN thinking and principles. Develop standard processes and incorporate efficiencies into daily workflow.
• Assist and contribute to the overall achievement of the Michigan Medicine and Revenue Cycle’s quality, operational and financial goals and objectives.