Pre-Certification Specialist

POSITION SUMMARY:

Responsible for timely verification of benefits and prior authorizations for all physicians and physical therapists.

ESSENTIAL RESPONSIBILITIES:

• Updates and maintains patient demographics as needed.

• Verify eligibility of benefits from the provider’s schedule, real time, 3 days prior to scheduled appointments. Review credentialing for accuracy and contract information.

• Verify referrals if needed and obtain referral from PCP.

• Obtain eligibility and prior authorizations for DME, assigned surgeries and outside testing and physical therapy.

• Coordinate with Front Office, Medical Records, Medical Assistants and Account Representatives on above data.

• Maintains files with insurance authorizations and referral information.

• Assist in covering team member’s work, when others are out.

• Works overtime hours as needed.

• Adheres to company policies as described in employment handbook and company work rules.

• Participates in professional development activities and opportunities.

• Attends staff meeting and others as required.

• Maintains confidentiality of patient account information in accordance with HIPAA guidelines and NMOA policy.

• Regular and reliable attendance.

• Performs any other duties as assigned.

SUPERVISORY RESPONSIBILITIES:  N/A

KNOWLEDGE, SKILLS AND ABILITIES:

To perform this job successfully, an individual must be able to perform each essential responsibility satisfactorily.  The requirements listed below are representative of the knowledge, skills and/or abilities required.

• Exceptional customer service skills.

• Knowledge of current basic medical terminology, coding, eligibility and prior authorization knowledge and office procedures.

• Strong computer and phone skills, including multi-line phones.

• Excellent grammar and spelling skills.

• Ability to establish and maintain effecting working relationships with staff, co-workers, patients and vendors.

• Ability to add, subtract, multiply and divide in all units of measure, using whole numbers, common fractions, decimals and percentages.

• Ability to understand, read, write and speak English. Ability to understand and speak Spanish preferred.

• Ability to read, analyze and interpret medical information, technical procedures and/or general business information.

• Ability to effectively present information, respond to questions and professionally interact with managers, employees, patients, vendors and the general public.

• Ability to recognize and define problems, collect data, establish facts, draw conclusions and correct errors.

• Ability to interpret a variety of instructions in a variety of forms and deal with abstract and concrete variables.

• Ability to handle multiple simultaneous tasks effectively and efficiently while maintaining a professional, courteous manner.

• Exhibit understanding of healthcare regulatory and compliance policy (e.g., HIPAA).

• Knowledge of New Mexico Orthopaedics policies and procedures to include Operating Agreement, Medical Staff Bylaws, Business Office Standards and Recommended Practices.

• Requires ability to identify and implement opportunities to improve performance of the department.

• High integrity, including maintenance of confidential information.

• Exhibit patience in high stress situations and handle confrontations with poise and efficiency.

• Ability to work a flexible schedule, including some evenings and weekends.

• May be assigned to or transferred to any clinic location, depending upon business need

PHYSICAL DEMANDS AND WORK ENVIRONMENT:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job responsibilities.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit for extended periods of time; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, bend, crouch or crawl; talk or hear; or smell.  The employee must occasionally lift and/or move up to 20 pounds.  Repetitive motion of upper body required for extended use of computer. Requires vision correctable to 20/20 and hearing in the normal range for face-to-face and telephone contacts.

Works in well-lit, ventilated and climate controlled office environment with routine office equipment; some equipment has moving mechanical parts.

Noise level in the work environment is usually moderate.

EDUCATION AND/OR EXPERIENCE:

High School Diploma or GED and two years of relevant experience. Pre-verification and Prior Authorization experience in a medical office setting preferred.

CERTIFICATIONS, LICENSES, REGISTRATIONS:

None required