Precertification Specialist WMCG

Core Responsibilities And Essential Functions

• Knowledge of all Outpatient Infusion exams in all modalities, including patient preps and instructions.
• Demonstrate understanding of scheduling/Outpatient infusion.
• Knowledge of CPT codes, Diagnosis codes and/or reasons for procedures (ICD-10).
• Knowledge of testing frequencies based on insurance and Medicare guidelines.
• Knowledge of various insurance programs offered by each carrier (TPA).
• Knowledge of Medicare guidelines regarding infusions that require Medical necessity checks.
• Knowledge of insurance carriers requirements for Pre-Authorization of procedures and referrals for procedures.
• Knowledge of the lead time required by an insurance carrier to process pre-auth referral numbers.
• Assist the physicians office with ICD-9 and ICD-10 codes for Medicare Medical necessity by referring to the coding helpline.
• Assist the physicians offices with pre-authorization process.
• Knowledge of electronic orders (Epic, Image Now, Trace).
• Provides appropriate telephone etiquette and scripting.
• Ability to type with a high degree of accuracy and computer skills to accurately input data, Pre-authorization referral number in the appropriate field in Epic to ensure claim is generated in a timely manner.
• Maintain accurate and thorough notes when updating authorization status.
• Obtain pre-authorization numbers from physicians offices on all required procedures.
• Excellent communication and interpersonal skills to effectively deliver pending preauthorization issues to the patient, their representatives, facility and/or physician offices in a timely manner to eliminate potential revenue loss, customer satisfaction issues, patient responsibility.
• Explain available options (ABN, reschedule, Peer to Peer, insufficient information, Financial Responsibility form etc)
• Observe the guidelines of the authorization Policy & Procedure when communicating Authorization status to our customers.
• Verify the accuracy of data entered and correct any errors.
• Superior attention to detail.
• Assist with monthly reports as requested.
• Keeps current with insurance requirements for preauth.
• Working knowledge of assigned referral work queues.
• Responsible for meeting the demands of the assigned facility schedule.
• Assists with work queues as requested (Claim Edits, Accounts, etc).
• Assume other duties as needed to support the staffing needs of the department (May be delegated on a daily basis).
• Able to exercise judgment in taking appropriate actions in emergent situations, take initiative when problem solving, retain composure in stressful situations and escalate issues as necessary.
• Maintain neat attire, hair and appearance, following the department dress code.
• Acts in a way that demonstrates deep personal integrity and serves as a positive example.

Customer Focus and Communication

• Customer FocusEngagement (Internal and External Customers)
• Ability to interact respectfully with co-workers, patients, referring office staff in a friendly, personable and professional manner.
• Promote positive working relationships with co-workers, Team Leads, Supervisors and Managers.
• Orientates new employees and assures proper documentation of training.
• Assists other areas when needed.
• Flexible with hours to meet department needs.
• Assist in the interview process of new hires if asked.
• Understands existing lines of communication and authority, handles communications properly and is dependable and cooperative.
• Meets Service Recovery and Customer Service guidelines as needed.
• Initiate escalation process if authorization cannot be obtained.
• Views oneself as a reflection of the organization by following through on commitments and accepting ownership of any mistakes he/she might make.
• Work collaboratively with the team to determine areas of optimization and develop solutions.
• Takes responsibility for own actions, including the impact of those decisions on patients and others.

Mentoring, Training and Education

• Keep current knowledge of lead time required by insurance carriers to process preauth request.
• Assist Supervisor with training of new employees.
• Analyze patient medical records.