The specialist is responsible for identifying scheduled patients needing pre-certification, gathering necessary patient data and clinical documentation, and contacting insurance companies to obtain authorizations and determine benefits. They must coordinate follow-up to ensure procedures are authorized before the service date while meeting all payor requirements for payment.
Requirements summary
A high school diploma or equivalent is preferred, along with one year of experience in pre-certifications, medical billing, registration, or related healthcare business education. Candidates must maintain current knowledge of payor provisions, coding requirements (ICD-9/ICD-10, CPT), and be able to work independently while meeting productivity standards.
high schoolClinical DocumentationProductivity ManagementConfidentiality AdherenceEligibility VerificationCPT CodingICD-10 CodingPre-certificationComputer Software UtilizationAuthorization CoordinationInsurance Follow-upPre-determinationPayor RequirementsBenefit DeterminationPeer to Peer CommunicationFinancial Responsibility CommunicationNetwork Status Determination
Job description
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.
Benefits
Dental Insurance
Disability Insurance
Life Insurance
Paid Parental Leave
Paid Time Off
Vision Insurance
Medical Insurance
Tuition Reimbursement
On-Demand Pay
Employee Discounts
Career Advancement Opportunities
Well-being Programs
FSA Options
Educational Opportunities
Certification Reimbursement
HSA Options
Caregiver Leave
Financial Education
Annual Recognition/Awards Events
Partner Appreciation Days
Family Entertainment/Attractions Discount
Community Service/Improvement Opportunities
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.
PAY RANGE: $17.57 - $26.36 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 For over 135 years, Mercyhealth has provided high-quality health care to residents throughout northern Illinois and southern Wisconsin.
We have a passion for providing comprehensive health care close to home for area residents through our six hospitals and 85 primary and specialty care locations.
As an integrated health system, you can come to us for routine health care, like annual physicals, immunizations and preventive health screenings, as well as highly specialized care, such as neonatal intensive care, heart surgery, stroke care, neurosurgery, cancer treatment and much more.
The range of Mercyhealth's specialties and the skills of our doctors, nurses and clinical staff are truly extraordinary.
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