Job Description

The incumbent in the position processes preauthorization/precertification forms for the Department of Surgery. This person will assist in maintaining a departmental managed care manual as well as updating faculty and staff in the department regarding changes in the managed care process. This person will interact with physicians, nurses, and secretarial staff in the Department of Surgery as well as insurance companies, patients, and other departments or clinic areas.

I. Preauthorization/Precertification 85%

• A. Verifies accuracy of billing codes of routine, non-complex medical health claims related to processing of pre-authorizations/precertifications of patient procedures (e.g., diagnostic tests, inpatient and outpatient surgery, rehab and DME). This involves discussion with physician or nurse, reviewing the patient's medical record for necessary documentation and disseminating the appropriate information to the managed care/insurance company in order to secure approval of patient procedures.
• B. Provide faculty and staff with updates regarding changes made to managed care/insurance procedures and/or protocols.
• C. Assist in maintenance of a central resource manual of managed care/insurance company plans.
• D. Respond to routine, non-complex inquiries from physicians, nurses, hospitals, government agencies, insurance companies, managed care companies and patients concerning requests for assistance to assure appropriate coverage for planned medical services.
• E. Receive and respond to patient calls regarding insurance questions, precerts, authorizations, etc.
• F. Identifies, analyzes and takes necessary action in the review of insurance denials in order to determine the appropriate course of action required to accurately complete the medical review process.
• G. Secure additional health information from the patient and/or physician regarding the episode of care being denied and initiate follow-up discussions with insurance organizations in order to obtain a medical review.
• H. Correspond with physician, nurses, hospitals, government agencies, insurance companies, managed care companies, and patient as required to identify and collect the information required to complete the authorization process.
• I. Obtain standard, established codes acquired from ICD-9 and CPT coding books after chart review and/or discussion with physician or nurse and disseminate to the certifying insurance agency.
• J. Maintain accurate records of preauthorization/precertification process through entering appropriate information into computerized system.
• K. Create computerized precertification forms to make the process more efficient.

II. Administrative 15%

• A. Attend training sessions, meetings, and conferences and read publications to remain current on the policies and procedures of managed care/insurance companies.
• B. Participate in SIU Physicians & Surgeons committees as requested.
• C. Other duties/projects as assigned.

Qualifications

1. High school diploma or equivalent.

2. Any one or combination totaling six (6) months from the categories below:

• 1. College coursework in a health-related field, business administration/management, human resource management, or closely related fields, as measured by the following conversion table or its proportional equivalent: 30 semester hours equals six (6) months
• 2. Work experience in a healthcare environment working with medical claims, denials, rejections, referrals, and/or prior authorization.