Description
PURPOSE OF THIS POSITION
The Post-Acute Pre-Certification Specialist is responsible for initiating and obtaining new insurance authorization requests for post-acute services. Works collaboratively with the case management team, hospital care team, community partners and insurance companies to ensure that patient care needs are met regarding post-acute care prior authorizations. Obtains and maintains contacts with insurance companies to streamline barrier removal. Maintains knowledge of proper portal functionality and medical necessity requirements for post-acute care. Understands payer requirements and how to apply benefits in various circumstances for post-acute care and is responsible for identifying medical criteria for post-acute care from chart review and developing an effective clinical packet to justify the level of care needed.
JOB DUTIES/RESPONSIBILITIES
Duty 1: Initiates and manages the pre-certification process for patients transferring to post-acute care. This includes collecting necessary patient information, submitting requests to insurance companies via portals, websites, or other required methods, and tracking the status of authorizations.
Duty 2. Communicates with interdisciplinary teams. Works closely with clinical staff, physicians, and other relevant departments to gather necessary clinical documentation and facilitate the approval process.
Duty 3. Organizes and maintains accurate documentation. This includes patient records, clinical documentation, and all correspondence related to authorization requests.
Duty 4. Addresses and manages denials, communicates denied authorization requests to relevant parties and facilitates the appeals process for post-acute care placement.
Duty 5. Documents all activities and communications related to the pre-certification process within relevant systems (e.g., EHR, patient management systems).
Duty 6. Maintains positive relationships with managed care providers and works to ensure patient and provider satisfaction.
Duty 7. Stays updated on payer policies and requirements and acts as a resource to team members and patients.
Duty 8. Complies with HIPAA regulations and ensures confidentiality of patient information.
Duty 9. Demonstrates excellent communication, organizational, and problem-solving skills.
- Duty 10. Utilizes relevant technology and software platforms. This includes EHR systems, prior authorization management software, and insurance portals.
REQUIRED QUALIFICATIONS
High School Diploma or GED equivalent.
Previous experience in a medical office, hospital, or skilled nursing setting, specifically with managed care pre-certification.
Knowledge of Medicaid, Medicare and Managed Care procedures.
Understanding of insurance verification and authorization processes.
Familiarity with medical terminology and coding (CPT/ICD-10).
Proficiency in using computer systems, including Microsoft Office applications and relevant healthcare software (e.g., EHR systems, insurance portals).
Strong organizational and time management skills.
Excellent communication and interpersonal skills.
Ability to work independently and as part of a team.
Detail oriented and accurate.
A valid driver's license is required (if you do not have a valid Ohio driver's license you must obtain one within 30 days of your residency in the state). You must also meet BVHS's company fleet policy and insurance company requirements, and any other requirements that may be required to operate a vehicle.
Positive service-oriented interpersonal and communication skills required.
- Individual must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patient served on his/her assigned unit/department. The individual must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient status. Must be able to interpret the appropriate information needed to identify each patient's requirements relative to their age-specific needs and to provide the care needed as described in the area's policies and procedures
PREFERRED QUALIFICATIONS
- Some related college preferred.
- Insurance verification and authorization submission/verification experience preferred.
- Knowledge of EHR and insurance verification/authorization software.
- Ability to meet remote work requirements.
PHYSICAL DEMANDS
This position requires a full range of body motion with intermittent walking, lifting, bending, climbing, squatting, kneeling, twisting, sitting and standing. The associate must be able to lift 20-30 pounds or more. The individual must have excellent eye-hand coordination with the ability to grasp, push and pull, have fine fingers dexterity and manipulation. The associate must be able to reach work above the shoulders. This position requires corrected vision and hearing in the normal range. The associate must have excellent verbal skills to communicate with patients, physicians, and co-workers.
This position is classified “at risk” for possible occupational exposure to blood borne pathogens (HBV, HIV, etc.)
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