Precertification Specialist 1

OVERVIEW:

Responsible for identifying patients requiring pre-certification or pre-determination, verifying insurance eligibility and benefits, obtaining necessary clinical documentation, and securing authorizations to ensure procedures are approved before the date of service. Maintains accurate patient account documentation, communicates with insurance companies, provider offices, and financial counselors to resolve coverage issues and support reimbursement while ensuring compliance with payer requirements and patient confidentiality policies. Demonstrates strong organizational, communication, and problem-solving skills while meeting productivity and accuracy standards, providing training and mentoring, and maintaining current knowledge of insurance regulations and coding requirements.

SCHEDULE: Remote Full-Time, 40 hours per week.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Identify all scheduled patients requiring pre-certification or pre-determination through various systems.
• Identify all relevant patient data elements and information from the various systems to acquire precertification.  
• Contacts insurance companies or employer groups to obtain pre-certifications, predeterminations, and determine eligibility and benefits for necessary services.
• Make necessary contact to follow up if there are insurance issues in order to obtain financial resolution.
• Obtain necessary clinical documentation to use in the pre-certification process.
•  Coordinates follow-up timely to ensure procedures are authorized and documented prior to the date of service while ensuring all payor requirements are met to ensure payment.
• Communicates with designated Mercy Partners, Patient Financial Counselors regarding outcome of pre-certifications, benefits and patient financial responsibility.
• Obtains insurance information to complete payor requirements.
• Maintains current knowledge of payor payment provisions and regulations.
• Keep current of ICD-9/ICD-10 and CPT coding requirements.
• Ability to utilize computer software to complete pre-certification processes.
• Meets department productivity and accuracy expectations.
• Understands and follows patient confidentiality policies.
• Ability to determine network status, eligibility, and coverage for patients to ensure reimbursement for services. Maintains current knowledge of payor payment provisions and regulations. 
• Communicate in a professional, respectful manner with provider offices regarding peer to peer information for follow-up ensuring authorizations can be obtained for procedures pended for medical review.
• Follows documentation standards on all patient encounters on appropriate patient account utilizing notes. Ensures account is updated to accurately reflect the current status.
• Ability to work independently with minimal supervision and be result oriented. 
• Provide training and mentoring
• May be required to work alternate shifts, weekends and overtime during peak periods. 
• Participates in educational programs to meet mandatory requirements and identified needs with regard to position and personal growth.
• Performs other duties as assigned.

EDUCATION AND/OR EXPERIENCE

High school diploma or equivalent preferred.
One year of pre-certifications, medical billing, registration, healthcare experience, or other business or healthcare related education preferred. 
 

CERTIFICATION/LICENSURE

N/A

OTHER SKILLS AND ABILITIES
Excellent oral communication skills/organizational skills
Ability to handle stress and problem solve
Computer experience required
Knowledge of Epic preferred
Able to work independently
 

LEVEL OF SUPERVISION

Some independent judgment is required, but alternatives are limited by standard practices or procedures.

SUPERVISES

This position has no supervisory responsibility

PAY RANGE:

Mercyhealth is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identify, national origin, disability, or protected veteran status.

Mercyhealth offers competitive pay and a comprehensive benefits package including:

• Medical, Dental, Vision

• Life & Disability Insurance

• FSA/HSA Options

• Generous, accruing paid time off

• Paid Parental and caregiver leave

• Career advancement and educational opportunities

• Tuition and certification reimbursement

• Certification Reimbursement

• Well-being Programs

• Employee Discounts

• On-Demand Pay

• Financial Education

• Annual recognition/awards events

• Partner appreciation days

• Family entertainment/attractions discount

• Community service/improvement opportunities

Click here for more details regarding Mercyhealth Careers Benefit Information.

At Mercyhealth, we don’t simply hire people, we empower employee-partners who are passionate about making lives better. As an integrated health system, we deliver exceptional, coordinated across seven hospitals, 85 primary and specialty clinics, and a team of over 7,500 professionals serving northern Illinois and southern Wisconsin.

Mercyhealth has been nationally recognized for our commitment to our people and culture, including:

• #1 in the nation on AARP's Best Employers for Workers Over 50

• One of Working Mother magazine's 100 Best Companies for Working Mothers

• A Top 50 Company and Top 10 Nonprofit for Executive Women