Responsible for the completion of pre-certification, prior authorization and notification for third party and government payers for all pre-scheduled elective inpatient and outpatient examination and procedures requiring preauthorization. May provide back-up pre-certification/prior authorization resources for other departments as needed. Coordinates/educates physicians, nursing staff and other health care providers on the pre-certification process and requirements. Tracks, documents, and monitors pre-certifications. Implements checks and balance systems to ensure compliance.
Essential Job Functions
•Supports and practices the mission and philosophy of Billings Clinic and Radiology Department.
•Coordinates pre-certification process with provider offices to ensure target goal of 98% of pre-scheduled elective inpatient and outpatient procedures are pre-authorized.
•Documents and maintains patient specific pre-certification/authorization data within the required information systems. Compiles, documents, and tracks monthly pre-certifications using established procedures.
•Keeps undated list. Ensures correct patient status when pre-certifying.
•Reviews CPT-4 codes of required pre-certification and/or authorizations; ensuring Passport pre-certification process is also met.
•Reports denials and/or delays in the pre-certification process to physicians/other health care providers and the patient. May provide information to the patient on the appropriate appeal procedures for denials.
•Responsible for coordinating resolution of varied problem situations and performing necessary investigation and research to resolve pre-certification problems.
•Reports non-compliance issues and/or needs for program expansion to Manager.
•Works closely with Medical Staff, Payer Relations and Patient Financial Services to coordinate needed pre-certification authorizations for in-network services.
•Tracks and verifies receipt of pre-certification authorizations has been received either verbally or written. Communicates status to providers and patients as needed.
•Develops and maintains collaborative working relationships with payers and health care providers.
•Reviews, updates and standardizes forms and processes as needed
•Participates in interdepartmental meetings to coordinate efforts, work through processes, and foster communication.
•Develops and maintains reference manuals that outline the individual payer requirements as it relates to pre-certification and pre-authorization needs.
Responsible for the integrity and accuracy of the payer data
•Assists patients/family members with status of pre-certification or re-certification information.
•Identifies needs and sets goals for own growth and development; meets all mandatory system/department requirements. Maintains knowledge of current trends and developments as it relates to the pre-certification process.
•Maintains competency in all organizational, departmental and outside agency environmental, employee or patient safety standards relevant to job performance.
•Performs other duties as assigned or needed to meet the needs of the department/organization.
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