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Precertification Specialist

Wellstar Shared Services • Marietta, GA • Professional • 113400 • Days, Evenings, Weekend Option • PRN


The Outpatient Infusion (OPIC) Pre-Authorization Specialist functions under the direction of the OPIC Manager. Provides outstanding customer service to customers in a fast-paced busy environment. Drive volumes and increase revenue by obtaining Pre-Authorization for Outpatient Infusion in a timely Manner. Observing Quality and Productivity standards and other Key Performance Indicators. 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, claim edits, and reconsiderations when needed. Support Revenue cycle. Must be flexible with work hours to meet department needs.


*This is a Remote position but must be flexible with working some weekends*


Core Responsibilites and Essential Functions

  • Pre-Authorization Duties
    * Knowledge of all Outpatient Infusion exams in all modalities, including patient preps and instructions.
    * Demonstrate understanding of scheduling/Outpatient infusion.
    * Knowledge of CPT codes, Diagnosis codes and/or reasons for procedures (ICD-10)
    * Knowledge of testing frequencies based on insurance and Medicare guidelines.
    * Knowledge of various insurance programs offered by each carrier (TPA)
    * Knowledge of Medicare guidelines regarding infusions that require Medical necessity checks
    * Knowledge of insurance carriers? requirements for Pre-Authorization of procedures and referrals for procedures.
    * Knowledge of the lead time required by an insurance carrier to process pre-auth referral numbers.
    * Assist the physician?s office with ICD-9 and ICD-10 codes for Medicare Medical necessity by referring to the coding helpline
    * Assist the physicians? offices with pre-authorization process
    * Knowledge of electronic orders (Epic, Image Now, Trace)
    * 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
    * Superior attention to detail
    * Assist with monthly reports as requested
    * Keeps current with insurance requirements for preauth
    * 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?)
    * Assume other duties as needed to support the staffing needs of the department (May be delegated on a daily basis)
    * 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
    * Maintain neat attire, hair and appearance, following the department dress code.
    * Acts in a way that demonstrates deep personal integrity and serves as a positive example.
  • Customer Focus and Communication
    * Customer Focus?Engagement (Internal and External Customers)
    * 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, Team Leads, Supervisors and Managers.
    * 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.
  • Mentoring, Training and Education
    * Keep current knowledge of lead time required by insurance carriers to
    * process preauth request.
    * Assist Supervisor with training of new employees
    * Analyze patient medical records

Required for All Jobs

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


Required Minimum Education

  • High School graduate Required or
  • equivalent Required

Required Minimum Experience

  • minimum 1 year experience in customer service and/or healthcare setting Preferred and
  • minimum 1 year experience in insurance / benefits Preferred

Required Minimum Skills

  • Strong customer service skills, 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 (see WellStar?s ?Standards of Gold? and ?Values?).
  • 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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