Patient Referral Assistant

Pre-certification/Denials Specialist

The Pre-certification/Denials Specialist is responsible for obtaining prior authorizations for all procedural orders by successfully completing the authorization process with all government and commercial payers. They will obtain and communicate via the electronic medical record to clinic personnel, providers, and hospital scheduling department. The position will be a primary liaison with third party/managed care insurers to stay informed of the latest changes, developments with pre-authorization referral procedures. This position will be responsible for the review and follow up of all pre-authorization denials. Position is productivity driven and will be monitored for performance measurements.

Responsibilities

Completes prior authorizations related to Pain Management procedures and medications. Works with providers, office staff & outside sources to complete third party referral authorizations accurately and timely.

Review chart documentation (EPIC EMR experience preferred) to ensure patient meets medical policy guidelines, prioritize incoming authorization requests according to urgency, obtain authorization via payer website or phone and follow up regularly on pending cases until complete.

Maintain individual payer files to include up to date requirements needed to successfully obtain authorizations, initiate appeals for denied authorizations, respond to clinic questions regarding payer medical policy guidelines, and confirm accuracy of CPT codes and ICD-10 diagnoses in procedure orders.

Other duties and responsibilities:

Ability to handle multiple tasks and stressful situations.

Must be able to communicate verbally in person, on the phone and in writing. Frequently position requires regular public contact, decision making and exposure to stress.

MyMichigan Health is a technology driven organization and employees need to demonstrate competency in Microsoft Windows. An employee may be required to participate in further learning opportunities.

Experience, Training and Skills

Two to four years medical office experience with knowledge in payer medical policy guidelines.

Excellent interpersonal/customer relations skills and be able to work independently required

Advanced medical terminology, knowledge of obtaining prior authorizations, ICD9/ICD10, CPT coding.

Experience within physician practice and knowledge of third payer rules, and medical record charting/documentation experience required.

Clinical experience preferred.

Established written and verbal communication skills, good organization and prioritization skills.

Must be a proficient computer user; experienced in Windows, Word Processing, and medical practice software and possess Medic Computer knowledge. Experience in database application and skills preferred.

Physical/Mental Requirements and Typical Working Conditions

Exposure to stressful situations, including those involving public contact, as well as, trauma, grief and death.

Able to wear personal protective equipment that includes latex materials or appropriate substitute if required for your position.

Is able to move freely about facility with or without an assisted device and must be able to perform the functions of the job as outlined in the job description.

Overall vision and hearing is necessary with or without assisted device(s).

Frequently required to sit/stand/walk for long periods of time. May require frequent postural changes such as stooping, kneeling or crouching.

Some exposure to blood borne pathogens and other potentially infectious material. Must follow MyMichigan Health bloodborne pathogen and TB testing as required.

Ability to handle multiple tasks, get along with others, work independently, regular and predictable attendance and ability to stay awake.

Overall dexterity is required including handling, reaching, grasping, fingering and feeling. May require repetition of these movements on a regular to frequent basis.

Physical Demand Level: Sedentary. Must be able to occasionally (0-33% of the workday) lift or carry 0-10 lbs.