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Job Summary:

A WMG Pre-certification Specialist I is responsible for obtaining pre-certification/authorization for outpatient diagnostic procedures for practice and HOD visits and ensuring referrals are completed timely.
The WMG Pre-certification Specialist I position reports directly to the WMG Central Precertification Manager.
Key responsibilities:
The WMG Pre-certification Specialist I function under the direction of the Manager of Centralized Precertification. Provides outstanding customer service to their dedicated physician practice. This position supports practice volumes and increasing revenues by obtaining Pre-Authorization for outpatient testing, outpatient diagnostic and medications in a timely manner while maintaining the required 3 day out ahead of the practice's schedule. Consistent review of payer authorization policies to ensure all procedures are authorized in a timely manner. Utilize various departmental tools and appropriate reports to identify and trend any on-going issues with payers and physician practice processes resulting in fatal denials. This position works with physicians, nurses, clinic managers and financial advocates to resolve issues that arise during the prior authorizations process. This position may also support Pre-Registration including preparing patient estimates. Maintain established productivity benchmarks and meets goals in a fast-paced environment. Other duties as assigned.
Impact of this role in the organization:
The WMG Pre-certification Specialist I impact to the organization improves Patient Experience and operational workflow in respect to Patient Access to services within WMG practices.

Core Responsibilities and Essential Functions:

Quality/ Safety Knowledge of all Outpatient Procedures.
- Review and analyze medical record documentation to include medical diagnostics, and procedural information for various medical and surgical procedures requiring authorization.
- Demonstrate understanding of scheduling and updating patient insurance information.
- Ensures all authorizations are requested with the appropriate CPT codes, diagnosis codes and/or reasons for procedures (ICD-10) including clinical data to support request.
- Acts as the liaison between the specialist, primary care physician and insurance carrier to ensure appropriate authorization for specialty procedures. Communicates all insurance concerns to the specialist.
- Knowledge of various insurance programs offered by each carrier (TPA)
- Knowledge of Medicare guidelines in reference to surgeries and procedures that require Medical necessity checks.
- Knowledge of insurance carriers requirements for pre-authorization of surgeries and procedures including the referrals for procedures.
- Knowledge of the lead time required by an insurance carrier to process pre-auth referral numbers.
- i Knowledge of the ICD-10 codes for Medicare Medical necessity by referring to the coding helpline.
- Knowledge of the system data input for the hospital access to the prior-authorization number.
- Ability to type with a high degree of accuracy and computer skills to accurately input data, Preauthorization 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.
- Excellent communication and interpersonal skills to effectively deliver pending preauthorization issues to the patient, their representatives, facility and/or the hospital 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 patients
- 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 pre-auth
- 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, Referrals etc)
- Assume other duties as needed to support the staffing needs of the department (May be delegated on a daily basis)
- Ability to exercise judgment in taking appropriate actions in emergent situations, take initiative when problem solving, retain composure in stressful situations and escalate issues as necessary
- Maintain neat attire, hair and appearance, following the department dress code.
- Acts in a way that demonstrates deep personal integrity and serves as a positive example. Customer Service
- Greets all guest with a positive and professional attitude.
- Receives patients valuables for safekeeping in the hospital safe.
- Answers incoming phone calls and follows through with requests made.
- Maintains courteous and cooperative working relationships with WHS management, patients, physicians, other professional contacts, and the general public. Demonstrates ability to tactfully handle difficult situations.
- Presents a well-groomed and professional image in coordination with dept/ hospital dress codes. Expected Performance, Behaviors and Results: The WellStar Experience (Must demonstrate a commitment to Service Excellence by):
- Creating first impressions, memorable moments and impressions that fulfill the expressed and unexpressed wishes and needs of patients and family members.
- Valuing patients and family members as partners in their care.
- Having world-class processes in place.
- Delivering high-touch care that is reliable, responsive and coordinated.
- Focusing on constant innovation and creating improvements.
- Celebrating our diversity with sensitivity and understanding.
- Embracing the idea that we are all owners of our health system. Budget/Financial
- Responsible for keeping departmental pre-certification denials to less than of net revenue.
- Prevent procedure cancellation due to authorization denials.
- Ensure all payor authorizations are appropriately obtained.
- Ensure policy coverage and benefits will cover services. General
- Observes work hours and provides proper notice of absences, tardies work schedule changes.
- Attends select departmental meetings at the request of WHS Management.
- Completes monthly, quarterly, and annual mandatory training as required.
- Performs other duties as assigned.
- PAS II Team members serve as preceptors and mentors and as such must:
- Maintain a based on individual QA audit /or as reported by Epic (min. of 10 accounts) registration accuracy rate or higher in the past 12 months.
- Maintain minimum productivity requirements.
- Has no corrective disciplinary action during the past twelve (12) months.
- Willing and able to function as a preceptor in the orientation of new patient access personnel and students.
- Maintain required certifications by obtaining necessary CEUs and submitting timely to certifying board.

Required Minimum Education:

• High School Diploma General or GED General or Associates Other-Preferred

Required Minimum License(s) and Certification(s):
All certifications are required upon hire unless otherwise stated.

Additional License(s) and Certification(s):



Required Minimum Experience:

Minimum 1 year experience in customer service and/or healthcare setting Required or
Minimum 1 year Computer/data entry experience or experience in insurance / benefits Preferred or

Required Minimum Skills:

Ability to communicate with various members of the healthcare team.
Effective communication skills (both written and verbal),
attention to detail
self-directed
positive attitude
Effective problem solving and critical thinking skills.
Working knowledge of patient registration systems

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