JOB SUMMARY

Notifies insurance payers of member admission (and observation if required).  Secures all necessary hospital admission and observation /authorizations pre-certifications in a timely manner.  Reviews and resolves pre-authorization/pre-certification issues.  Responsible for notifying appropriate hospital personnel of insurance and benefit updates and changes, upon discovery.  Responsible for gathering and submitting all necessary clinical documentation with pre-certification/authorization initially and as directed by insurance payer and Case Management leadership. Adheres to organizational policies and procedures; regulatory/accrediting body requirements and professional practice standards, including Health Insurance Portability and Accountability Act (HIPPA).

PRIMARY JOB RESPONSIBILITIES

• Comply with all local, state and federal regulations
• Timely submission of patient information
• Verifies that all pre-certification and/or authorizations have been obtained and documented in the HIS system
• Will update authorization or pre-certification as needed
• Assumes responsibility and accountability for individual knowledge, skills, performance and behavior in accordance with hospital, division and department standards of care and policies and procedures
• Utilizes measures to promote and maintain patient, visitor and personnel safety
• Maintains patient, employee, physician and organization confidentiality; respects the rights, privacy and property of others
• Supports the mission, values and vision of the organization

ADDITIONAL RESPONSIBILITIES

• Assists in the orientation and training of new personnel
• Demonstrates knowledge of disaster/emergency procedures and responds appropriately
• Maintain effective communication with all internal and external customers providing outstanding quality of service
• Perform tasks that are supportive in nature to the essential functions of the job
• Participate in staff meetings, educational programs, committees, QI activities and mandatory in-services
• Demonstrate initiative in personal/professional development
• Presents a professional image
• Assist with costs through the judicious use of human and material resources
• Other duties as assigned

Requirements Include

EDUCATION AND WORK EXPERIENCE

• High School Diploma
• Medical terminology, ICD10 and CPT coding skills required.
• Knowledge of third party payer processes preferred and compliance regulations processes
• Knowledge of Medicare and Medicaid payers
• 3-5 years healthcare experience required
• Experience with insurance authorizations preferred

KNOWLEDGE AND SKILLS

• Must be able to problem-solve multi-task and work independently
• Must have outstanding customer service and telephone communication skills  
• Must be able to adjust to change
• Must be PC literate with skills in windows, email and internet navigation
• Must be able to type
• Must be able to perform professionally during high stress and high patient volume times