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Precert & Denials Spec OPIC

Wellstar Cobb Hospital • Hiram, GA • Professional • 114689 • Days • Full-Time


The Outpatient Pre Cert/Denial Specialist functions under the direction of the Manager of Outpatient Infusion Center. Provides outstanding customer service to customers in a fast paced busy environment. Drive volumes and increase revenue by obtaining Pre-Authorization for Outpatient Treatments. Responsible for performing a wide variety of clerical procedures that requires independent judgment, ingenuity and initiative in the utilization of computers and other equipment. Knows the existing lines of communication and authority, handles communications properly and is dependable and cooperative. Works with staff and understands appropriate scheduling and authorization process, willing to learn procedures/patient preps. Assist Scheduling, patient and physician's office staff with authorization issues in a timely manner. Communicate any authorization issues with the patient and provider within 24 hours of the patients' appointment. Make all efforts to avoid Denials, assist with Denials, reconsiderations when needed. Support Revenue cycle. Must be flexible with work hours to meet department needs.


Core Responsibilites and Essential Functions

  • Pre-Authorization/Denial Duties
    * Knowledge of all Infusion Therapies including patient preps and instructions.
    * Demonstrate understanding of scheduling/ Infusion Therapy Procedures.
    * Knowledge of CPT codes, Diagnosis codes and/or reasons for procedures (ICD-10)
    * Knowledge of therapy frequencies based on insurance and Medicare/Medicaid guidelines.
    * Knowledge of various insurance programs offered by each carrier (TPA)
    * Knowledge of Medicare guidelines in reference to therapies that require Medical necessity checks
    * Knowledge of insurance carriers? requirements for Pre-Authorization of procedures/therapies and referrals for procedures/therapies.
    * Knowledge of the lead time required by an insurance carrier to process pre-auth referral numbers.
    * Assist the physician?s office with ICD-10 codes for Medicare Medical necessity by referring to the coding helpline
    * Assist the physicians? offices with pre authorization process
    * Knowledge of electronic ordering process.
    * Provides appropriate telephone etiquette and scripting.
    * Ability to type with a high degree of accuracy and computer skills to accurately input data, Pre authorization referral number in the appropriate field in Epic to ensure claim is generated in a timely manner.
    * Maintain accurate and thorough notes when updating authorization status.
    * Obtain pre-authorization numbers from physicians? offices on all required procedures.
    * Excellent communication and interpersonal skills to effectively deliver pending preauthorization issues to the patient, their representatives, facility and/or physician offices in a timely manner to eliminate potential revenue loss, customer satisfaction issues, patient responsibility. Explain available options (ABN, reschedule, Peer to Peer, insufficient information, Financial Responsibility form etc?)
    * Observe the guidelines of the authorization Policy & Procedure when communicating Authorization status to our customers
    * Verify the accuracy of data entered and correct any errors
    * Works to have denials overturned by providing appropriate documentation and participates in Denial Review meetings.
    * Assist with monthly reports as requested
    * Keeps current with insurance requirements for preauthorization
    * Working knowledge of assigned referral work queues
    * Responsible for meeting the demands of the assigned facility schedule.
    * Assists with work queues as requested (Claim Edits, Accounts, etc?)
    * Ability to exercise judgment in taking appropriate actions in emergent situations, take initiative when problem solving, retain composure in stressful situations and escalate issues as necessary

  • Customer Focus and Communication
    * Ability to interact respectfully with co-workers, patients, referring office staff in a friendly, personable and professional manner
    * Promote positive working relationships with co-workers, nurses, and manager.
    * Orientates new employees and assures proper documentation of training
    * Assists other areas when needed
    * Flexible with hours to meet department needs
    * Assist in the interview process of new hires if asked
    * Understands existing lines of communication and authority, handles communications properly and is dependable and cooperative
    * Meets Service Recovery and Customer Service guidelines as needed
    * Initiate escalation process if authorization cannot be obtained.
    * Views oneself as a reflection of the organization by following through on commitments and accepting ownership of any mistakes he/she might make.
    * Work collaboratively with the team to determine areas of optimization and develop solutions
    * Takes responsibility for own actions, including the impact of those decisions on patients and others.
  • Other Duties and Tasks
    * Keep current knowledge of lead time required by insurance carriers to process preauthorization requests.
    * Assist Manager with training of new employees as appropriate
    * Analyze patient medical records
    * Support the needs of the department by performing tasks such as answering the phone, transporting specimens to the lab, picking up medications from the pharmacy, reconcile appointment book, order office and medical supplies (May be delegated on a daily basis)

  • Required for All Jobs

  • Performs other duties as assigned
  • Complies with all WellStar Health System policies, standards of work, and code of conduct.

  • Qualifications

    Required Minimum Education

  • High School graduate Required or
  • equivalent.

  • Required Minimum Experience

  • Worked in healthcare setting performing prior authorizations. Required and
  • Minimum 2 years experience in insurance / precertification Preferred and
  • Minimum 1 year experience Required

  • Required Minimum Skills

  • Strong customer service skills, good communication skills and organizational skills.
  • Basic typing and data entry experience.
  • Experience in computer usage and Medical Terminology preferred.
  • The individual must be able to communicate and understand verbal and written English language and display a positive attitude.
  • This position requires a high level of attention to detail and a low error rate, as the consequences of even a minor mistake can be significant for patients and providers.
  • In addition, this position requires regular, reliable attendance.

  • Required Minimum License(s) and Certification(s)

    Additional Licenses and Certifications

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