[Hiring] Pre-Certification & Authorization Coordinator @Tufts Medicine

Role Description

This role focuses on activities related to revenue cycle operations including, but not limited to billing, collections, cost estimates, and payment processing. In addition, this role focuses on performing the following Patient Access duties:

• Performs the administrative and financial-clearance duties necessary to facilitate the procurement of clinical services by patients.
• Collects patient's necessary demographic and financial information from physician offices, acute-care entities, or the patients themselves.
• Schedules services for patients and handles referrals from primary care doctors to ensure patients are scheduled for recommended appointments/procedures.
• Most of the time is spent in the delivery of support services or activities, typically under supervision.
• An entry-level role that typically requires little to no prior knowledge or experience.

Qualifications

• High school diploma or equivalent.
• Two (2) years of related experience in a hospital, physician office, or financial services.
• Associate’s degree (Preferred).
• Five (5) years of related experience in a hospital, physician office, or financial services (Preferred).

Requirements

• Contacts insurance companies and workers compensation carriers to obtain verification of insurance, eligibility, and level of benefits.
• Contacts patients for updates of financial and demographic information.
• Obtains financial data from various sources including both in-state and out-of-state payers.
• Arranges for coordination of benefits when more than one insurance carrier is involved.
• Seeks administrative approval of admission (precertification) for surgeries, admissions, procedures, imaging, outpatient specialty referrals, home health, hospice, and all other in-scope services.
• Identifies procedures & services that are not covered by individual insurance policies.
• Communicates all identified financial risk concerns to the ordering department and Patient Access leadership.
• Collaborates with Financial Coordination and Pre-Registration colleagues regarding patients with identified financial risk concerns.
• Obtains all applicable clinical documentation when required by insurance payers for elective services.
• Closely follows case statuses and communicates/document in the hospital system.
• Immediately identifies denied claims and works closely with department leaders toward their appeal and peer-to-peer workflow.
• Monitors productivity and quality of workflow directly.
• Acts as a resource to other departments regarding precertification policies and resolution of accounts.
• Maintains collaborative, team relationships with peers and colleagues.
• Works closely with Case Management and Admitting colleagues to confirm level of care changes.
• Learns and adapts to new workflow changes and updates.
• Assists in the training and shadowing of new team members.

Benefits

• Comprehensive Total Rewards package that supports health, financial security, and career growth.
• Fair, competitive pay that attracts, retains, and motivates highly talented individuals.
• Base pay range: $20.12 - $25.15.

Physical Requirements

• Frequent sitting, occasional standing & walking, and lifting of 5-10 lbs.
• A valid driver’s license is required for local travel to remote hospital sites.
• Mental requirements will be intense at times with involvement in many concurrent multi-faceted projects.
• Requires manual dexterity using fine hand manipulation to operate a computer keyboard or related equipment.
• Requires ability to see computer screen, monitoring equipment, and reports.

Skills & Abilities

• Knowledge of medical terminology.
• Knowledge of ICD-10 and CPT coding.
• Thorough working knowledge of insurance, payer precertification requirements for in-network, out-of-network, Medicare, and Medicaid.
• Knowledge and willingness to learn computer systems (Microsoft Word/Excel).
• Strong verbal and written communication skills with a patient service focus.
• Excellent organizational skills, ability to prioritize work assignments, and attention to detail.
• Ability to respond effectively to changing priorities and work processes.
• Ability to work independently and participate in teams.
• Strong customer service skills including excellent interpersonal and telephone skills.
• High degree of tact due to frequent interaction with patients, physicians, and insurance companies.
• Knowledge and understanding of health care delivery systems with emphasis on the referral management process for managed care providers.