Description

JOB PURPOSE: Contacts insurance companies and other third party payers to determine pre-certification, pre-authorization and/or medical necessity requirements for complex outpatient hospital services, and specialized procedures (i.e. Recurring Visits, Surgeries, IR). Obtains pre-certification or pre-authorization prior to the scheduled complex service being performed. Liaisons with physicians and physician office staff when needed to obtain additional demographic, insurance or clinical information. Notify payers of admittance if required.

KEY RESPONSIBILITIES:
Obtain pre-certifications, authorizations and referrals to ensure managed care compliance through either direct contact, website, or insurance tool.
Enter authorization and all pertinent information into EPIC including whom spoken to.
Apply critical thinking skills to identify and resolve opportunities to avoid a denial from payers or the insurance companies to maximize reimbursement.
Follow Piedmont policies and procedures for requirements that the payers (insurance companies) have for the procedure scheduled.
Strive for positive patient experience.
Obtain, enter, and update demographic and other financial and clinical information necessary for financial clearance of scheduled patient accounts.
Ensure all required data elements are collected and validated for account creation in Revenue Cycle systems.
Ensure payer is notified of admittance if required.
Strong ability to estimate patient financial responsibility for complex procedures.