Precertification Associate - Northeast Georgia Physicians Group NGPG - Psychiatry - FT Days - Northeast Georgia Health System, Inc

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Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

About the Role:

Job Summary

The Precertification Associate obtains pre-certifications or authorization from insurers for facility and professional medical service for their insured members. Obtain precertification of cases as defined by procedures and policy. Make necessary contacts to complete pre-certifications. Develops and manages relationships with insurer precertification departments, physician office staff, physicians and FAHC patient access staff. This position is one member of the overall team required to run a clinic. 

• Licensure or other certifications:

• Educational Requirements: High School Diploma

• Minimum Experience:

• Other:

• Preferred Licensure or other certifications:

• Preferred Educational Requirements:

• Preferred Experience: One (1) year of pre-certification experience

• Other:

• Ability to work independently, emotionally mature, and able to function effectively under stress

• Excellent problem-solving and analytical skills

• Excellent written and oral communication skills

• Ability to prioritize, organize and coordinate daily work load

• Working knowledge of Protected Health Information

• Ability to manage change

• Extensive knowledge of medical terminology

• Must possess detailed understanding and knowledge of insurance guideline and protocols, the components of full verification and payer information/requirements

• Identify procedures and admission types requiring precertification. Build file of payer requirements. Identify appropriate resources and access payer reference guides for additional detail. Identify insurer utilization review phone numbers for each insurer, by employer. 

• Identify clinical information required by each payer for common procedures and admissions. Identify information usually required in initial phone contact to payer. Identify common follow-up info required. Obtain information from staff or from patient record as necessary.

• Identify demographic info required by each payer for common procedures and admissions. Identify insurance eligibility information required to obtain precertification. Obtain information from staff or from patient record as necessary. Utilize FAHC systems and payer systems to access and communicate relevant information. 

• Obtain precertification authorization from insurers for professional charges associated with elective or urgent admissions or inpatient/outpatient procedures. Prioritize contacts to insurers based on same day for urgent cases, within one week for elective cases. Contact insurers to provide them the patient clinical and demographic information they need for precertification. Obtain precertification and communicate approval number to relevant billing, scheduling, admitting and utilization management departments. Obtain additional clinical information if payer requires it. Arrange for payer to discuss case further with clinician if needed. If payer declines to pre-certify the case, obtain the reasons for the denial and discuss with the requesting physician. Initiate the appeal process. Identify areas of concern or inconsistency with precertification process. 

• Obtain precertification authorization from insurers for institutional charges associated with elective or urgent admissions or inpatient/outpatient procedures. Prioritize contacts to insurers based on same day for urgent cases, within one week for elective cases. Contact insurers to provide them with the patient clinical and demographic information they need for precertification. Obtain precertification and communicate approval number to relevant billing, scheduling, admitting and utilization management departments. Obtain additional clinical information if payer requires. Arrange for payer to discuss case further with a clinician if needed. If payer declines to pre-certify the case, obtain the reason for the denial and discuss with the requesting physician. Initiate appeal process. Identify areas of concern or inconsistency with precertification process. 

• Maintain appropriate data to accurately track activity. Maintain log of payers, patients, and results of calls using Access database or Excel spreadsheet. Tabulate monthly report of pre-certifications obtained, initial denials, reversals, and appeals for each physician. Prepare monthly report of precertification activity for each payer. Identify and track trends and problems and report them to management for further action. 

• Weight Lifted: Up to 50 lbs, Frequently 31-65% of time

• Weight Carried: Up to 50 lbs, Frequently 31-65% of time

• Vision: Heavy, Frequently 31-65% of time

• Kneeling/Stooping/Bending: Frequently 31-65%

• Standing/Walking: Frequently 31-65%

• Pushing/Pulling: Frequently 31-65%

• Intensity of Work: Frequently 31-65%

• Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding, Driving

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals. 

NGHS: Opportunities start here.

Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.