Precertification Specialist Resume Samples

Description :

1. Ensured the effective and efficient use of services, monitors appropriateness and medical necessity, and provides necessary information for authorization and continued stay/visit re-authorization.
2. Provided support to the patient accounting department to clarify claim submission and claim denial appeal efforts.
3. Assisted with patient intake.
4. Interacted as an active liaison between hospitals, medical facilities, surgical schedulers, medical doctors, Insurance Companies, and via another precertification specialist.
5. Reviewed information for admission and continued visit management including type and duration of service, authorization and CPT/HICPIC/ICD-10 codes for treatment, re-authorization and continued visit requirements necessary for ongoing treatment and payment.
6. Responsible for explaining benefits, the billing process and financial responsibility to parent/guardian.
7. Responsible for obtaining and communicating pre-authorization as needed per insurance company requirements.

Experience

2-5 Years

Level

Executive

Education

High School Diploma

Description :

1. Obtained patients clinical history and insurance documents from referred physician's office.
2. Scaned and documented patient's demographics to initiate precertification process.
3. Coordinated patients scheduling changes according to certification status.
4. Obtained authorization for various procedures for cardiac services.
5. Included office visits and nuclear testing.
6. Obtained referrals when required and delegating clinicals to third party companies for testing.
7. Worked one on one with doctor and nurse case managers to justify services rendered.

Experience

7-10 Years

Level

Senior

Education

BS

Description :

1. Responsible for obtaining complete and accurate insurance information, benefit verification, accurately interpreting benefit plans and investigating pertinent details.
2. Notified supervisor of known or potential insurance coverage issues.
3. Reviewed information for admission and visit management including type and duration of service, authorization and treatment codes, re-authorization and visit requirements necessary for ongoing treatment and payment.
4. Responsible for explaining benefits, the billing process and financial responsibility to parent/guardian.
5. Responsible for obtaining and communicating pre-authorization as needed per insurance company requirements.
6. Responsible for tracking, obtaining and extending authorizations from various carriers in a timely manner, requesting input from appropriate team members as needed.
7. Appealed for additional services (extended stays, visits, authorization extension, letter of medical necessity) and refers to additional resources when necessary.

Experience

5-7 Years

Level

Junior

Education

High School Diploma

Description :

1. Insuranced eligibility check and verification of benefits.
2. Scheduled surgeries with patient at local hospitals, or surgical center.
3. Obtained authorizations for procedures, including documentation, and setting up of peer to peers.
4. Verified all physical therapy benefits, and order all DME equipment, as well as all discharge plans to rehabilitation centers.
5. Completed booking sheets, and all pertinent information from labs, primary care doctors, and radiology facilities.
6. Verified consents forms and all information is gathered for surgery.
7. Responsible for prescription refills, answers to patient and insurance question, and mailing out of all patient information.

Experience

5-7 Years

Level

Executive

Education

Case Management

Description :

1. Called patient's insurance company to verify eligibility and obtain benefit coverage for office visits, outpatient tests, surgery, and inpatient admissions.
2. Attempted to obtain, and documented in the computer system, referral details and referral modifications for specialty care and testing for patients with insurance plans requiring formal referral documentation.
3. Obtained and documented in the computer system the pre-certification/pre-authorization number from insurance companies prior to each surgical procedure and diagnostic test.
4. Assisted patients with scheduling new patient office visits with CVCP provider offices.
5. Created and distributed the CVCP Inpatient and Outpatient Service Lists and manifests to CVCP surgeons and consultants.
6. Completed all fields within the computer system necessary to process claims and re-route claim to the billing department per assigned deadline.
7. Distributed The Admit List daily by 1 p.m., identify possible CVCP patients and distribute list to pre-certification staff for processing.

Experience

2-5 Years

Level

Executive

Education

Certificate In Business

Description :

1. Obtained authorizations for many referring doctors, between 800-900 a month.
2. Verified insurances, checking eligibilty.
3. Greeted patients, checking in patients, and making sure all patients information is accurate.
4. Answered questions of co-workers and solving patients questions.
5. Assisted the tech's when needed.
6. Assisted over 100 doctors a month with precertifications and making sure their patients are scheduled accurately.
7. Worked with prescribing physicians to determine patients' eligibility for insurance coverage of prescription medications.
8. Evaluated medical diagnoses, state laws and previous treatments to determine exceptions to formulary plan coverage.

Experience

10+ Years

Level

Senior

Education

Nursing

Description :

1. Answered phones with multiple lines.
2. Pre-certified insurances for Physical Therapy.
3. Scheduled patients using Sage Intergy.
4. Assisted the Doctor with EMG/NCS diagnostic testing.
5. Answered inquiries from persons entering establishment.
6. Collected and distributed mail and messages.
7. Responsible for pulling medical records and phoning patients for appointments.

Experience

10+ Years

Level

Senior

Education

Diploma In General

Description :

1. Recorded insurance information to maintain data through the Referral/Insurance Verification process and communicates insurance information to pertinent staff including therapists, coding and finance.
2. Independently maintained and worked from the electronic medical record and additional databases.
3. Responsible for obtaining complete and accurate insurance information, benefit verification, accurately interpreting benefit plans and investigating pertinent details.
4. Notified supervisor of known or potential insurance coverage issues.
5. Responsible for accurate determination of payor sources and communication to those payor sources relating to each patient visit.
6. Primary contacted for outpatient families regarding insurance referring them to the patient accounting department as needed Responsible for explaining benefits, the billing process and financial responsibility to parent/guardian.
7. Responsible for tracking, obtaining and extending authorizations from various carriers in a timely manner, requesting input from appropriate team members as needed.

Experience

7-10 Years

Level

Management

Education

Project Management

Description :

1. Assisted with greeting incoming patients, completing/distributing paperwork, entering pertinent patient information into the electronic medical record, and verifying insurance eligibility.
2. Assisted in the development, organization and maintenance of role specific documents, policies, and tools.
3. Worked independently and manage work time Document accurately and record patient/insurance information Speed and accuracy in data entry Medical .
4. Helped develop the policies for the Precertification Department which was implemented throught all Mercy facilities.
5. Corrected any account in which errors have occurred per assigned deadline.
6. Maintained communication among the physician, insurance company, and CVCP at all times regarding authorization and CVCP Auth status on patients.
7. Enrolled customers in specialized care programs Managed financial spending accounts Processed determination letters based on insures clinical .

Experience

7-10 Years

Level

Management

Education

Associates In Medical Billing

Description :

1. Responsible for pulling doctors schedules daily and obtaining clinical information needed to obtain prior authorization from insurance companies for all surgeries and diagnostic testing.
2. Generated referrals to insurance companies.
3. Communicated authorizations to hospital and doctors.
4. Registered insurance info in computer.
5. Precertified all surgeries and diagnostic testing in a fast paced multi-specialty practice.
6. Used Extremely detailed oriented, multi-tasking efficient, excellent time management skills.
7. Experienced with fast pace office environment, customer service experience, administrative and clerical expertise, strong organizational skills, efficient in meeting deadlines, task oriented with minimal supervision required.

Experience

10+ Years

Level

Senior

Education

BS In Dietetics