- Accurately and efficiently identifies all appropriate and necessary clinical documentation to support medical necessity for all scheduled procedures/medication orders for multiple service lines and clinics.
- Submits authorizations and clinical information to the appropriate payer/benefit manager in a timely fashion in compliance with plan rules including appropriately utilizing the CMS IP Only list.
- Assesses orders to determine appropriate patient class and works with physicians to clarify as necessary
- Contacts insurance plan/payers to determine eligibility, coverage information for specific procedures and benefit information
- Coordinates patient encounters using multiple systems applications, various registration applications, clinical operating systems, eligibility verification systems and medical necessity applications.
- Documents all findings/communications thoroughly and accurately in the patient record.
- Meets or exceeds productivity standards in the completion of daily assignments and accurate production.
- Documents all authorization information accurately in the referral as necessary to produce a clean transaction with the payer.
- Answer and responds to all communications through multiple applications in a timely and professional manner to ensure a positive patient experience.
- Complies with all departmental and organizational policies and procedures.
- Complies with local, state, and federal rules and regulations and the requirements of accrediting bodies.
- Prioritizes work according to the department, hospital, and patient needs.
- Independently works to resolve patient and provider questions related to prior authorizations, referrals, and insurance verification.
- Acts as a liaison between the patient, payer, provider and clinical support staff.
- Responsible for managing/setting up peer to peers and/or appeals for providers in a timely and professional manner according to individual plan guidelines.
- Work with all necessary parties to ensure patients are rescheduled/ notified of denials promptly.
- Responsible for understanding and staying current and up to date on payer regulations.
- Accurately provide expected timeframes /payer guidelines to patients and providers regarding prior authorization/ financial clearance.
- Maintains compliance with all company policies, procedures and standards of conduct
- Complies with HIPAA privacy and security requirements to maintain confidentiality at all times
- High School Diploma or equivalent (required)
- At least one year of patient access, insurance verification, prior authorization, or related experience (required)
- 3 years of prior authorization or related experience (preferred)
- Medical Terminology preferred
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Precertification Specialist- ENT - Louisville, United States - UofL Health
Description
UofL Health is a fully integrated regional academic health system with five hospitals, four medical centers, nearly 200 physician practice locations, more than 700 providers, the Frazier Rehab Institute and Brown Cancer Center.
With more than 12,000 team members—physicians, surgeons, nurses, pharmacists and other highly skilled health care professionals—UofL Health is focused on one mission: delivering patient-centered care to each and every patient each and every day.
The Precertification Specialist sets the precedence to ensure a positive patient experience for upcoming surgical procedures and diagnostic tests by accurately and efficiently completing all necessary steps related to prior authorization, medical necessity determination and financial clearance for the hospital system and physician services for clinics, adult acute facilities and diagnostic centers.
Performs other duties as assigned
Education:
Experience:
