JOB TITLE:   Clinical support/Office Specialist/ Insurance Precertification

REPORTS TO:  Practice Manager

SUMMARY OF POSITION: 

1.         Ensure prior authorization obtained for all upcoming testing and procedures ordered by physicians

2.         Work closely with nursing staff, local hospitals and insurance companies to ensure upcoming procedures are covered by patient’s health plan.

3.         Honor patient and co-worker confidentiality

4.         Other duties may be assigned by the Practice Manager

 

DUTIES:

1.         Understand the different insurance plans and policies that are accepted by CVC and rendering facilities.

2.         Obtain precertification number on all testing and procedures that are ordered by a physician

3.         Determine patients in and out of network benefits and which rendering facility will be the most compatible with the patient’s insurance

4.         Process Yes You Can forms for all non-Medicare, Medicaid patients with out of network insurance for all testing and procedures done at Aultman Hospital

5.         Know the correct CPT and ICD-10 coding for the ordering test or procedure

6.         Keep in constant contact with the insurance company on pending cases

7.         Able to research and give clinical information to insurance nurse reviewers

9.         Contact hospitals or other rendering facilities with the prior authorization number prior to test or procedure

10.       Handles triage and consultations calls and coordinates with physicians, fellows, emergency room and referring physicians, and hospital floors to get patients seen.

11.       Review chart documentation to ensure patient meets medical policy guidelines

 

WORKING CONDITIONS:

1.         Normally works 8 hours per day - Monday through Friday with a scheduled lunch every day

2.         May require paid overtime before and/or after normal working hours

3.         Works in well lighted and well-ventilated office

4.         Expected to adhere to general office policy

5.         Will not be exposed to blood and body fluids

 

6.         Will spend majority of day in front of computer terminal entering data, using telephone, faxes, copiers and printers

7.         Subject to frequent interruption

 

REQUIREMENTS:

1.         Knowledge of procedure authorization and its direct impact on the practice’s revenue cycle

2.         Understanding of the payer medial policy guidelines while utilizing these guidelines to manage authorizations effectively

3.         Basic understanding of human anatomy, specifically cardiac

4.         Proficient use of CPT and ICD-10 codes

5.         Excellent computer skills including Excel, Word and internet use

6.         Detail oriented with above average organizational skills

7.         Plans and prioritizes to meet deadlines

8.         Excellent customer service skills communicate clearly and effectively

9.         Ability to multitask and remain focused while managing a high volume, time-sensitive workload

EDUCATION: 

High School Diploma or GED 2 years medical prior authorization experience preferred 3 years’ experience in a medical related field required