Pre-Certification Representative

Job Purpose

The Pre-Certification Representative is responsible for obtaining and providing accurate and complete data input for precertification/preauthorization from insurance companies

Duties and Responsibilities

• Works effectively with insurance companies to obtain pre-certification for services
• Places calls to various health plans to obtain appropriate precertification prior to the patient`s appointment
• Ability to understand/interpret documented clinical information and relay pertinent medical/clinical information to the insurance company
• Faxes to pre-certification request form to insurance company
• Maintains files and security of confidential information utilizing host system to scan and input data as per established procedures
• Verifies medical insurance information and documents in scheduling/registration modules
• Reviews claim denials and rejections
• Accurately enters and updates patient data, and other general data, into the computer system
• Patient intake; insurance verification, notification of copays/patient liability and confirmation of demographics
• Demonstrates knowledge of varied managed care insurance and regulatory guidelines
• Meets and maintains daily productivity/quality standards established in departmental policies
• Meets and maintains quality standards established in departmental policies
• Uses the MPower workflow system, client host system and other tools available to them to collect payments and resolve accounts
• Adheres to the policies and procedures established for the client/team
• Use, protect and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
• Communicate effectively with physician offices and patients.
• Place outbound call to patients with precertification notification.
• Work independently from assigned work queues
• Maintain confidentiality at all times
• Maintain a professional attitude
• Other duties as assigned by the management team

Qualifications

• High School diploma or equivalent required
• Medical terminology knowledge required
• Minimum of 2-3 years of healthcare or physician's office related experience in obtaining and handling pre-authorizations
• Extensive knowledge of individual payor websites, including eviCore, Navinet and Novitasphere
• Knowledge of Medical Terminology, CPT Codes, Modifiers and Diagnosis Codes
• Ability to work well individually and in a team environment
• Strong organizational and task prioritization skills
• Proficiency with MS Office. Must have basic Excel skillset
• Experience with GE Centricity or EPIC PB preferred
• Strong communication skills/oral and written
• Strong organizational skills

Working Conditions

• Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear.
• Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress.
• Work Environment: The noise level in the work environment is usually minimal.

Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state or local law.