Pre-Certification Representative

About the role

The Pre-Certification Representative is responsible for obtaining and providing accurate and complete data input for precertification/preauthorization from insurance companies.

Responsibilities

• Works effectively with insurance companies to obtain pre-certification for services
• Places calls to various health plans to obtain appropriate precertification prior to the patient's appointment
• Ability to understand/interpret documented clinical information and relay pertinent medical/clinical information to the insurance company
• Faxes pre-certification request forms to insurance companies
• Maintains files and security of confidential information utilizing host system to scan and input data as per established procedures
• Verifies medical insurance information and documents in scheduling/registration modules
• Reviews claim denials and rejections
• Accurately enters and updates patient data, and other general data, into the computer system
• Patient intake; insurance verification, notification of copays/patient liability and confirmation of demographics
• Demonstrates knowledge of varied managed care insurance and regulatory guidelines
• Meets and maintains daily productivity/quality standards established in departmental policies
• Uses the MPower workflow system, client host system and other tools available to collect payments and resolve accounts
• Adheres to the policies and procedures established for the client/team
• Communicates effectively with physician offices and patients
• Places outbound calls to patients with precertification notification
• Works independently from assigned work queues
• Maintains confidentiality at all times
• Maintains a professional attitude
• Other duties as assigned by the management team
• Uses, protects and discloses patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
• Understands and complies with Information Security and HIPAA policies and procedures at all times
• Limits viewing of PHI to the absolute minimum as necessary to perform assigned duties

Qualifications

• High School diploma or equivalent required
• Medical terminology knowledge required
• Minimum of 2-3 years of healthcare or physician's office related experience in obtaining and handling pre-authorizations
• Extensive knowledge of individual payor websites, including eviCore, Navinet and Novitasphere
• Knowledge of Medical Terminology, CPT Codes, Modifiers and Diagnosis Codes
• Ability to work well individually and in a team environment
• Strong organizational and task prioritization skills
• Experience with GE Centricity or EPIC PB preferred
• Strong communication skills (oral and written)
• Strong organizational skills
• Proficiency in Microsoft Office Suite
• Strong interpersonal skills, ability to communicate well at all levels of the organization
• Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analyses
• High level of integrity and dependability with a strong sense of urgency and results oriented
• Excellent written and verbal communication skills required
• Gracious and welcoming personality for customer service interaction

Working Conditions

Must possess a smart-phone or electronic device capable of downloading applications, for multifactor authentication and security purposes.

Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear.

Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress.

Work Environment: The noise level in the work environment is usually minimal.