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PRE-CERTIFICATION SPECIALIST

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Allied Health
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057597 Requisition #
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The Pre-Certification Specialist is responsible for the completion of pre-certification, prior authorization and notification for third party and government payers for all pre-scheduled elective inpatient/outpatient procedures and diagnostic testing.  He/she is responsible for communicating with insurance companies and/or physician’s offices to ensure the pre-certifications are obtained.  He/she must maintain compliance with regulatory requirements.

The Pre-Certification Specialist must demonstrate Customer Focus (15) and expert Functional/Technical Skills (24) while providing pre-certification evaluation of each scheduled inpatient or outpatient patient case.  The Pre-Certification Specialist must comprehend the clinical aspect of the chart and how to apply it to ensure authorization of the accounts.  The Pre-Certification Specialist is required to maintain excellent customer service standards at all times in order to effectively communicate with physicians, physician offices, insurance representatives, patients, and co-workers. Pre-Certification Specialists are required to efficiently perform all duties while ensuring patient confidentiality and privacy rights.

JOB QUALIFICATIONS
Education:   High school diploma or GED required.  Associate Degree in related healthcare or

                             business field preferred.                    

Licensure:     N/A     

Certification: Medical Terminology Certification preferred.

Experience:  Two years of Patient Access, Health Information Management, Physician Office, Billing, Collections or Compliance experience required.  Applicable class work may be substituted for previous work experience.

 

                   Two Years of previous insurance experience and/or pre-certification experience preferred.  

 

·         Demonstrate knowledge of medical terminology and basic anatomy/physiology.

·         Equivalent combination of education and experience will be considered.

 

Skills/Other:

1.      Ability to perform a variety of tasks, often changing assignments on short notice.

2.      Must be adept at multi-tasking, organizing, priority, and time management.

3.      Will be required to learn and work with multiple software/hardware products to be used during the course of an average work day.

4.      Must possess excellent communication skills, both verbal and written.

5.      Most possess excellent telephone skills.

6.      Must be able to maintain a professional demeanor in stressful situations.

7.      Must be adept with machinery typically found in a business office environment.

8.      Able to build productive relationships with all contacts.

9.      Must have analytical skills to resolve simple to semi-complex problems.

10.  Must be proficient in Windows-based computer technology, including keyboarding and typing at least 35 wpm.

 

Competencies:       

1.      Customer Focus (15): Is dedicated to meeting the expectations and requirements of internal and external customers.  Gets first-hand customer information and uses it for improvements in services.  Acts with customers in mind.  Establishes and maintains effective relationships with customers and gains their trust and respect.

2.      Deal with Ambiguity (2): Can effectively cope with change.  Can shift gears comfortably.  Isn’t upset when things are up in the air.

3.      Composure (11): Is cool under pressure.  Does not become defensive or irritated when things are tough.  Is considered mature.  Can be counted on to hold things together during tough times.  Can handle stress.  Is a settling influence in a crisis.

4.      Peer Relationships (42): Is seen as a team player and is cooperative.  Easily gains trust and support of peers.  Encourages collaboration.

5.      Patience (41): Is tolerant with people and processes.  Listens and checks before acting.

6.    Compassion (10): Genuinely cares about people.  Is concerned about his/her work and non-work problems.  Is available and ready to help.

7.    Time Management (62): Uses time effectively and efficiently.  Gets more don in less time than others.  Can attend to a broader range of activities.

8.    Interpersonal Savvy (31): Relates well to all kinds of people – up, down, and sideways, inside and outside the organization; builds appropriate rapport; builds constructive and effective relationships; uses diplomacy and tact; can diffuse even high-tension situations conforbably.

 

DIMENSION/SCOPE

 

Physical, Mental, and Environment Requirements  

1.    Employee is regularly required to sit, stand, walk, talk and hear.

2.    Must possess visual acuity and manual dexterity to perform computer data entry and other clerical aspects to the job.

3.    May bend, stoop, twist and reach in conjunction with the job requirements.

4.    May lift files, reference books, supplies and other documents up to 10 lbs.

5.    May walk and push a wheeled cart with a computer and supplies weighing up to 50 lbs.

6.    This is both a sedentary and active position.

7.    Must be able to prioritize tasks and determine appropriate sequence for task completion.

8.    Must be able to respond to patients’, physicians’ and other customers’ questions, concerns and comments in a professional manner.

9.    Is regularly exposed to noise associated with working around others in an office setting.

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