Precertification Specialist WMCG

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

Various (United States of America)

The Outpatient Infusion (OPIC) Pre-Authorization Specialist functions under the direction of the OPIC Manager. Provides outstanding customer service to customers in a fast-paced busy environment. Drive numbers and competence by newly obtains Pre-Authorization for Outpatient Infusion in a timely manner. Observing quality and productivity standards and other key performance indicators. Responsible for performing a wide variety of clerical procedures that requires independent judgment, ingenuity and initiative in the utilization of computers and and required or other equipment.

Knows the existing lines of communication and authority, handles communication properly and is dependable and cooperative. Works with staff and understands appropriate scheduling and authorization process, willing to learn procedures/patient preps. Assist scheduling, patient and physician's office staff with authorization issues in a timely manner. Communicate any authorization issues with the patient and provider within 24 hours of the patients' appointment.

Make all efforts to avoid denials, assist with denials, claim edits, and reconsiderations when needed. Support revenue cycle. Must be flexible with work hours to meet department needs.

Pre-Authorization Duties

• 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…