Tufts Medical Center Precert Verification Coordinator in Boston, Massachusetts

Precert Verification Coordinator

Department: Financial Coordination

Schedule: Full-Time Regular

Shift: Day shift

Grade: 7

Hours: Monday-Friday 8-4:30

Job Details:

  • Associate's degree is preferred

  • 1-2 years experience is required

  • GENERAL SUMMARY:

    Under the supervision of the Precertification Manager, is responsible for obtaining precertification and verification of benefits with all third party carriers for all inpatient and day surgery admissions in a timely fashion. Screens each inpatient and day surgery admission for clinical appropriateness in order to obtain prior approval from third party carriers. Collaborates and reviews clinical admission data with the Precertification Manager to ensure proper authorization for all admissions.

PRINCIPAL DUTIES AND ESSENTIAL FUNCTIONS:

¨ Contacts insurance companies to obtain verification of insurance, eligibility, and level of benefits. Enters benefit information into the SMS financial management system.

¨ Contacts patients, when necessary, for updates of financial and demographic information. Enters all data into the SMS computer system.

¨ Obtains financial data from a variety of sources including Medicaid and Blue Cross point of service devices. Utilizes computer system dial in services, i.e., Medicare system.

¨ Arranges for coordination of benefits when more than one insurance carrier is involved.

¨ Updates financial/insurance plan codes in the SMS Master Patient Index.

¨ Seeks clinical approval of admission (precertification) for day surgery and inpatient stays. Enters precertification information into the SMS clinical management system.

¨ Identifies surgical procedures that are not covered services by individual insurance policies. Refers all identified liabilities to the physician's office and Financial Coordination for immediate resolution.

¨ Refers all inpatient and day surgery patients with identified financial liability to Financial Coordination for resolution prior to services being rendered. Suggests postponement of elective procedures until financial arrangements are in place.

¨ Identifies surgical procedures that are not covered services by individual insurance policies. Refers all identified liabilities to the physician's office and Financial Coordination for immediate resolution.

¨ Screens each admission for clinical appropriateness and site-of-service.

¨ Obtains clinical documentation when requested by insurance carriers for elective inpatient and day surgery admissions.

¨ Immediately identifies "denied" claims and works toward their appeal.

¨ Statistically tracks volume of completed verifications and precertifications for management review. Maintains statistics regarding approvals, denials, and adjudication of claims.

¨ Acts as a resource to other departments of the hospital regarding precertification policies and resolution of accounts.

¨ Communicates clearly to all NEMC staff and Professional Billing Corporations all new regulations and changes mandated by insurance carriers.

¨ Maintains collaborative, team relationships with peers and colleagues in order to effectively contribute to the working groups achievement of goals, and to help foster a positive work environment

¨ Performs other similar and related duties as required or directed.

JOB REQUIREMENTS:

JOB KNOWLEDGE AND SKILLS:

¨ Thorough knowledge of medical terminology.

¨ Thorough working knowledge of MCAP criteria, ICD9 and CPT4 coding.

¨ Thorough working knowledge of all payor precertification requirements and managed care contracts.

¨ Thorough working knowledge of SMS, FMS, and CMS systems.

¨ Strong verbal and written communication skills. Must demonstrate a customer service focus.

¨ Excellent organizational skills and ability to prioritize work assignments. Ability to respond effectively to changing priorities and work processes.

¨ Ability to work independently but also participates in teams within the department.

EDUCATION:

¨ Level of knowledge generally acquired through completion of an Associates degree or equivalent experience.

EXPERIENCE:

¨ Two to three years related experience in a hospital setting or physician practice including previous experience with third party eligibility requirements.