Pre-Certification Specialist

Summary

• Position Summary

  • Performs required precertification activities to ensure reimbursement for outpatient services for specialty practices, including practices under professional services agreements and the related to treatments and procedures located at SJC sites. Works closely with insurance carriers and medical/hospital practices to ensure timely, accurate and complete documentation of clinical and administrative information related to outpatient infusion services and procedures. Communicates to the patients, the insurance approval status of all precertifications. Performs other responsibilities as needed.

• Education

  • High School Diploma - Preferred

• Experience

  • 2-3 Years medical background - Preferred

  • 1 Year insurance experience - Preferred

• License & Certification

  • None Required

• Core Job Functions

  • Demonstrates responsibility in maintaining patient records in organized and secure manner. Ensures HIPAA regulations are continuously followed.
  • Determines precertification necessity. Communicates and coordinates with insurance companies to maximize reimbursement. Communicates with other departments to eliminate denials from insurance companies.
  • Monitor various reports for precertification need. Perform initial review prior to date of service and concurrent review until precertification obtained. Communicate and collaborate with other departments to eliminate precertification denials.
  • Documents within EMR and hospital charting system data on precertification and payer correspondence. Ensures appropriate referral information is taken by the front desk staff to limit denial of services