GENERAL SUMMARY OF POSITION

Provides assistance to patients and providers by confirming and completing required pre-certification/authorizations prior to service to ensure a positive patient/provider experience and mitigate denials.

EDUCATION

• High School Diploma or GED required

EXPERIENCE

• 1-2 years Experience in patient accounting, patient access, or pre-arrival services functions, or an equivalent combination of experience and college education in accounting, finance or healthcare administration required

KNOWLEDGE, SKILLS, AND ABILITIES

• Working knowledge and demonstrated proficiency in payer authorization and clearance processes.
• Requires basic working knowledge of UB04, HCFA 1500 or equivalent and payer responses.
• Requires some knowledge of medical terminology and CPT/IDC-9 coding.
• Excellent communication, analytical, interpersonal, and organizational skills.
• Proficient uses of hospital registration and/or billing systems and personal computers as well as Microsoft Excel and Word applications.
• Ability to type 35 WPM.
  This position has a hiring range of $18.33 - $31.61

• Pre-Authorizations/Pre-Certification: Verifies eligibility and conformance to the department and departmental managed care requirements and contracts. References the MedStar Managed Care Matrix and online Handbook as necessary. Obtains insurance referrals and pre-authorizations. Submits all referral information to necessary providers, as appropriate; Assists with pre-authorizations of scheduled procedures, including hospital admissions, procedures, medications and medical equipment as required.
• Reviews all scheduled procedures and initiates authorization and pre-certification activities. Reviews all provider schedules confirms correct insurance information is available. Cross-references as needed to any application where documentation is stored to ensure completeness of work.
• Maintains ongoing communication with insurance companies to determine eligibility of benefits, deductible status, and to obtain precertification for assigned scheduled procedures. Responds to provider/hospital staff and/or patient inquiries regarding authorizations, and scheduling in an efficient manner.
• Pre-Authorization/Pre-Certification: Ensures all relevant data is entered into the IDX application, links data to the appropriate appointment/visit and enters the required data elements to ensure that accurate billing information is submitted to the appropriate insurance carrier. Obtains any missing pre-certification or authorization numbers and enters into the appropriate field in the Appointment Data Form (ADF) or other required fields as necessary. Communicates if the appointment needs to be rescheduled due to a missing Referral or Authorization number.
• Pre-Authorization/Pre-Certification: Confirms all relevant data is entered into SMS/Invision authorization fields to ensure accurate billing information is submitted to the appropriate insurance carrier. Obtains any missing pre-certification or authorization numbers and enters into the appropriate fields.
• Monitors and completes the MedConnect Pre-Authorization Work Queue as required with accurate authorization status and communicates with designated provider staff regarding any information required to complete the authorization requirements. This includes but is not limited to additional documentation, Peer-to-Peer requests, etc.
• Maintains current knowledge of regulatory and specific changes as it relates to Pre-Authorization and Pre-Certification requirements.
• Maintains daily performance benchmarks as it applies to interpreting and evaluating Pre-Authorization and Pre-Certification requirement to include follow up with payers and assigned providers
• Maintains departmental Quality Assurance standards within established error rate.
• Participates in PFS or PUBS workgroups, staff meetings and work events.