As an essential member of the Revenue Cycle team, Senior Pre-cert Specialists ensure authorizations for outpatient testing, ambulatory and inpatient services are obtained before services are rendered. The successful completion of tasks performed by this position, directly impacts denials and reimbursement from third party payers. Senior Pre-cert Specialists are skilled in patient/physician relations, registration, scheduling, and precertification

Essential Functions

• Verifies and pre-certifies inpatient and outpatient services to ensure appropriate reimbursement from third party payers, government payers and state agencies
• Mastery of skills relating to insurance coverage, benefits, rules & regulations and allocation of plans accurate information and fulfillment of requirements resulting in expected payment for services
• Verifies and allocates insurance plans utilizing electronic eligibility tools, phone calls payer, accesses web portals and initiates appropriate action for services including non-covered and out-of-network insurance services
• Submits timely electronic and verbal notifications and clinical documentation in accordance with contractual requirements and payer guidelines; coordinates with operations and clinical counterparts to obtain and submit necessary information and documentation
• Communicates potential issues and follows GM-98, Service with Authorization guidelines to notify providers of pending authorizations/denials and peer to peer requests; escalates encounters per policy
• Effectively communicates utilizing telephone, emails, or correspondence for internal and external customers; understand when and how to escalate cases that require operations and leadership attention to initiate appropriate action
• Maintains up-to-date knowledge of computer applications, insurance/government regulations, managed care guidelines and Revenue Cycle policies/procedures used within the department.
• Preceptor for new hires and provides necessary training at the direction of department leadership
• Participates in enterprise special projects as needed
• Leads work flow and process improvement project initiatives
• Provides feedback, suggestions and process improvement recommendations to management
• Scans and retrieves appropriate related documents in scanning applications
• Attends and participates in corporate and local team meetings and maintains patient / physician confidentiality.
• Ensures compliance with department productivity and quality standards

Additional Responsibilities

• Leads departments meetings as needed

Required For All Jobs

• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.