Pre-certification Specialist

Company: St Luke's University Health Network
Location: Phillipsburg
Posted on: May 3, 2021

Job Description:

St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.

The precertification specialist is responsible for contacting health insurance companies prior to physician/provider office visits, procedures, testing or admission to the hospital to verify coverage either online or by telephone. The precertification specialist is also responsible for relaying precertification information to performing facility and for facilitating appeals if initial approval is denied. Excellent phone skills and computer skills are needed. Previous medical terminology background is helpful.

1. Receives instructions from the physician/provider regarding what procedure or testing is needed.

2. Issue and/ or obtain precertification/preauthorization from insurance companies prior to procedure or testing utilizing an online application or contacting the insurance company by telephone.

3. Issue and/or obtain insurance referrals from insurance companies prior to physician/provider office visits utilizing an online application, a paper form or by contacting the insurance company by telephone.

4. Verifies patient eligibility and coverage for the procedure using an online application or by telephone. If the patient is not eligible on date of service or procedure is not covered, this information is relayed to the physician/provider and the patient.

5. Maintains online log of patient's requiring precertification.

6. Maintains working knowledge of Navinet and RadMD (online insurance referral and precertification application)

7. Demonstrates competency in assigned areas of responsibility.

8. Responds to written and telephone inquiries from patients, insurance carriers and facilities regarding planned services.

9. Maintains detailed knowledge of computer software systems as it relates to job functions.

10. Takes an active role in facilitation team approach to functions within the department:

o Attends departmental meetings

o Actively participates as a team member in resolution of problems as they are

o Analyzes current procedures, bringing suggestions for improvement to the attention

o Document authorizations in medical record and provide to appropriate sources.

11. Proficient in Electronic medical record program used in office.

12. Maintains confidentiality of all materials handled within the Network/ Entity as well as the proper release of information.

13. Complies with Network and departmental policies regarding issues of employee, patient and environmental safety and follows appropriate reporting requirements.

14. Demonstrates/models the Network's Service Excellence Standards of Performance in interactions with all customers (internal and external).

15. Demonstrates Performance Improvement in the following areas as appropriate: Clinical Care/Outcomes, Customer/Service Improvement, Operational System/Process, and Safety.

16. Demonstrates financial responsibility and accountability through the effective and efficient use of resources in daily procedures, processes and practices.

17. Complies with Network and departmental policies regarding attendance and dress code.

18. Demonstrates competency in the assessment, range of treatment, knowledge of growth and development and communication appropriate to the age of the patient treated.

19. Contacts Central Scheduling, Patient Access Department, and patient, to relay insurance referral and/or precertification information.

OTHER FUNCTIONS:

Assist other staff as needed. Other related duties as assigned.

PHYSICIAL AND SENSORY REQUIREMENTS:

The employee should be comfortable sitting up to eight hours a day. Continually using fingers for typing and writing. Routine use of upper extremities. Stoop, bend and reach above shoulder level regularly. Vision must be correctable to 20/20 and hearing must be in the normal range for telephone calls. Position also requires viewing computer screens and typing for long periods of time.

POTENTIAL ON-THE-JOB RISKS:

Repetitive motion injury of the wrist due to frequent computer use (adaptive modification of keyboard available).

Identified Risks:

Employees who work in patient care areas where they may have potential exposure to patients with suspected or proven tuberculosis (TB) must have the ability to wear a particulate respirator and be fit-tested in compliance with the current recommendations from the CDC (enforced by OSHA) or must provide physician documentation as to the inability to wear a particulate respirator.

SPECIFIC PROTECTIVE EQUIPMENT AVAILABLE: NONE

MOST COMPLEX DUTY:

* Ability to maintain a working knowledge of insurance and precertification requirements * Reviewing a patient's electronic chart for information that is needed when requesting precertification. * Ability to communicate effectively with physicians/providers, team members and patients. * Ability to prioritize work in an environment of constant change while meeting the needs of the office.

SUPERVISION (RECEIVED BY AND/OR GIVEN TO):

Practice Administrator

COMMUNICATIONS:

The employee must possess the ability to communicate effectively and appropriately with patients, insurance companies, physicians/providers and team members at both Southside Medical Center and Family Medicine - Easton Avenue. The employee must be assertive and pleasant in order to gather accurate and complete data and must be able to convey information to patients in a way that they can understand. The employee must know when it is appropriate to listen and must be able to remain calm, tactful and even-tempered in a variety of situations. The employee will communicate with the Southside Practice Administrator and with the Easton Avenue Practice Administrator effectively; and will relay information pertaining to personal absences (ex: PTO, Sick Days) to both administrators so that they are aware that other arrangements will need to be made to ensure that the referral and precertification work is completed by other team members at their offices.

ADDITIONAL REQUIREMENTS:

The employee must demonstrate a positive attitude in keeping with PCRAFT values. The employee must be customer service driven, motivated and ambitious; and should be able to enjoy working with people while finding it necessary, at times, to collaborate with peers in order to solve problems. The employee must possess problem solving and multitasking abilities in order to fulfill the requirements of this position.

MINIMUM QUALIFICATIONS

EDUCATION: High School diploma required.

TRAINING AND EXPERIENCE: Previous precertification experience helpful. Medical coding and terminology experience preferred.

WORK SCHEDULE: Day, middle or night shift with varying hours based on the needs of the department. Travel to satellite offices may be necessary.

Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!!

St. Luke's University Health Network is an Equal Opportunity Employer.

Keywords: St Luke's University Health Network, Bethlehem , Pre-certification Specialist, Other , Phillipsburg, Pennsylvania