Summary

Responsible for precertification of eligible medical services and procedures for inpatient, diagnostic, and outpatient services. Ensures complete documentation is obtained that meets insurer guidelines for medical necessity and payment for services. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.

Education/Experience/Licensure

Knowledge/Skills/Abilities

• Knowledge and experience in coverage practices, terminology, and requirements for referrals and authorization/pre-certification used by third party payers, Medicare, and secondary payer rules.
• Knowledge of CPT, HCPCS, and ICD-10 codes preferred.
• Demonstrated analytical ability to collect and interpret insurance and contract information.
• Experience dealing with PPO and Managed Care insurance.
• Strong attention to detail and critical thinking skills.
• Experience with a computerized healthcare information system required. Familiarity with fundamental Microsoft Word software.
• Excellent verbal and written communication skills.

Key Job Responsibilities

• Responsible for precertification of eligible medical services and procedures for inpatient, diagnostic, and outpatient services based on medical plan documents and medical necessity. Manages pre-certifications for more complex surgical and invasive procedures that require strong clinical knowledge.
• Coordinates all documentation required for precertification of services.
• Establishes a good working relationship with physicians, physician office staff, patients, and other members of the healthcare team.

Physical Requirements

• The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion.
• Must have good balance and coordination.
• The physical requirements of this position are: light work - exerting up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently.
• The Associate is required to have close visual acuity to perform an activity, such as preparing and analyzing data and figures; transcribing; viewing a computer terminal; or extensive reading.
• The conditions to which the Associate will be subject in this position: The Associate is not substantially exposed to adverse environmental conditions; job functions are typically performed under conditions such as those found in general office or administrative.