Overview Precertification Specialist, Patient Access, Days, 80 Hrs / 2 wks Location: Mercyhealth Hospital Walworth; Lake Geneva, WI Hybrid schedule opportunities available after probationary period. Responsible for correctly prioritizing and completing all steps of the scheduling, referral management, authorization, verification and registration process prior to patients receiving services. Identifies scheduling needs, reviews schedules, follows scheduling protocols and enters visit information for appropriate scheduling. Identifies, verifies, and captures appropriate patient demographic information and health insurance benefit eligibility information. Performs payer coverage investigation, as necessary, utilizing both internal and external tools and resources, to obtain reimbursement verification. Utilizes knowledge including, but not limited to, managed care, commercial, government, and work comp insurance billing requirements, as well as current coding guidelines and standards, to ensure resolution of pre-service edits, appropriate management of claims, initiation and direction of accounts for pre-authorization as required, prevention of timely filing claim denials, and procurement of appropriate reimbursement. This position requires understanding of healthcare Revenue Cycle and the importance of evaluating and securing all appropriate financial resources to maximize reimbursement to the health system. This position assumes clinical and financial risk of the organization when collecting and documenting information on behalf of the patient. Responsibilities Identify all scheduled patients requiring pre-certification or pre-determination through various systems. Review patient schedules and acquire all data elements and information from the various systems to acquire precertification. Contacts insurance companies or employer groups to obtain precertifications, predeterminations, and determine eligibility and benefits for necessary services. Make necessary contact to follow up if there are insurance issues in order to obtain financial resolution and payment on account. Obtain necessary clinical documentation to use in the pre-certification process. Timely documentation of referrals/authorizations/pre-certifications in appropriate systems. Coordinates follow-up to ensure all payor requirements are met and payment is expected. Communicates with designated Mercy Partners, Patient Financial Counselors regarding outcome of precertifications, benefits and patient financial responsibility. Obtains insurance information to complete payor requirements. Maintains current knowledge of payor payment provisions and regulations. Keeps abreast of denials related to pre-certification and assist with appeal of denials as needed. Keep current of ICD-9/ICD-10 and CPT coding requirements. Ability to utilize computer software to complete pre-certification processes. Participates in educational programs to meet mandatory requirements and identified needs with regard to position and personal growth. Maintains logs and documents activity timely within patient accounting system. Understands and follows patient confidentiality policies Education and Experience High school diploma or equivalent required. One year of healthcare registration, scheduling, or physicians' office experience required. Completion of 24 (twenty four) hours of coursework in a business or healthcare related field of study may be considered in lieu of healthcare office experience Special Physical Demands The Special Physical Demands are considered Essential Job Functions of the position with or without reasonable accommodations. While performing the duties of this job, the employee is regularly required to walk; use hands to finger, handle, or feel; reach with hands and arms; climb or balance; stoop, kneel, crouch, or crawl; and talk or hear. The employee is frequently required to sit and work at a computer for long periods of time. The employee is occasionally required to stand. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus. While performing the duties of this job, the employee must have good manual dexterity to operate keyboard and telephone; repetitive finger/wrist movement associated with use of keyboard; prolonged sitting. The employee must be able to lift or move office related objects Culture of Excellence Behavior Expectations