WMG PreCert Specialist I

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Work Shift

Day (United States of America)

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