Surgery Verification Specialist - Cincinnati, United States - UC Health

Description

This position will ensure surgery pre-certification/ prior authorizations are in place prior to the procedure.
High School Diploma or GED - Minimum Required ? Associates Degree - Preferred Degree | None | - 2 Years equivalent experience - Minimum Required ? - 5 Years equivalent experience - Preferred

Job Function:
Surgical/procedure Verification - 70% Reviews accounts for missing authorizations with the use of designated work queue.

Work accounts for financial security based on priorities of filters for days out, admit status, case specialty, procedure, or surgeon.

Contact appropriate precertification department or physician office if authorization or CPT codes are missing. Review for financial clearance (FAA, self-pay estimates or cosmetic payments) for cases without insurance coverage.

Escalating to manager of registration, utilization review manager, and director of finance when financial clearance has not been obtained timely.

Confirm insurance has been e-verified/edibility. Notify AU/IV if verification is not present. WCH campus responsibility includes endo, MIS, hospital surgical unit and surgery center. Start Medical Mutual of Ohio inpatient authorizations in review link for hospital authorization. Verify Workers comp C-9 online or call to confirm. Screen for OON plans. Assure that office has been notified, preservice collections has calculated financial responsibility and patient was notified.


Job Function:
Status Confirmation - 15% Verify admission status is correct based on inpatient only codes from CMS.

Check to make sure case request status in Epic match authorization status (inpatient vs outpatient) and that status request is appropriate.

Work closely with the utilization review nurse to assure status/authorization understanding. Work closely with admitting so clarify that authorization has been obtained for procedures in question.


Job Function:

Add-Ons Cases - 10% Assure that cases have been routed to the appropriate team responsible for precertification and insurance verification for eligibility.

For physicians with no Epic access, assure that media scan includes prior authorization status and CPT code. Contact physician office if no documentation is present.


Job Function:
Quality/Performance Improvement - 5% Maintain up to date knowledge of Medicare compliance and insurance requirements. Analyze denials from weekly report for process improvement and education to appropriate department. Assure all departments responsible for precertification have access to inpatient only procedure code list. Assist with Advance Beneficiary Notice (ABN) notice of non-coverage when necessary. Assure documentation is accurate, reflecting who was responsible for precertification and accuracy of information. | Review the physical demands and assign an overall average percentage of time this position performs these activities. These physical demands will not be listed or rated on the annual performance appraisal.


Climbing:
Ascending or descending stairs, ladders, ramps, etc, using feet and legs and /or hands and arms - 5% Stooping:Bending body downward and forward by bending spine at the waist - 5% Kneeling:Bending legs at knees to come to a rest on knee or knees - 5% Reaching:Extending hand(s) and arm(s) in any direction - 10% Standing: Remaining upright on the feet, particularly for sustained periods of time - 15% Walking:Moving about on foot to accomplish tasks - 15% Pushing 0-10 lbs:Use of upper extremities to press against something with steady force in order to move something forward, downward or outward - 10% Pushing 11-20 lbs: Use of upper extremities to press against something with steady force in order to move something forward, downward or outward - 10% Pushing 21-50 lbs: Use of upper extremities to press against something with steady force in order to move something forward, downward or outward - 10% Pushing 51 lbs or more: Use of upper extremities to press against something with steady force in order to move something f