Precertification and Insurance Verification

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Job description

General Summary

• The Insurance Verification/Prior Authorization Team Member is responsible for verifying patient eligibility, determining benefits, and to obtain insurance prior authorization prior to patient's exam date and time.

Essential Duties and Responsibilities

• Obtains or assists in receiving prior authorization/precertification from payers for surgical, laboratory, chemotherapy, radiation therapy and diagnostic imaging procedures scheduled to be performed.
• Processes multiple patient prior authorization/precertification requests at any given time in an efficient and accurate manner. Documents prior authorization/precertification decisions following clinical policy in clinical software.
• Confirms member plan eligibility and benefits prior to processing a request for pre-certification. Utilizes clinical knowledge, clinical resources or clinical policy as required.
• Makes and receives calls on the status of authorizations. The precertification team member speaks to the clinical nurse reviewer from the various insurance carriers on a daily basis to obtain pre-certifications.
• The precertification team member demonstrates knowledge of rules for all insurance payor guidelines.
• Pre-certification team demonstrates exceptional customer service and interacts effectively with physicians, patients, staff and the healthcare community.

Job Qualifications

• Education

  • High School diploma or Equivalent required. Additional training/Schooling such as a technical or junior college directly related to Medical Assistant/Medical Billing highly preferred.

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  Work Experience
  • Minimum 1 year of clinical experience in a health care organization required. Experience in insurance verification and prior authorization process preferred. Knowledge of Medical terminology and CPT & ICD-9/10 codes preferred.
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  Certification/License
  • Valid MO or Compact State LPN license or an accredited Registered Medical Assistant required if programs were completed.

Mental/Physical Requirements

• Ability to receive and express detailed information through oral communications, visual acuity, and the ability to read and understand written directions. Normal mental concentration with repetitive operations for a long period of time. Communicates well both verbally and in writing, creates accurate and punctual reports, shares information and ideas with others, has good listening skills. Ability to stand, walk, sit, and reach. Occasionally lifts and transports items weighing up to ten (10) pounds.

Working Conditions

• Standard office conditions with more than average noise. Periodic contact with conditions such as fumes, noise, chemicals, hazards, and/or diseases.