PART TIME BENEFITED, 40 HOURS PER PAY
The Pre-Admissions Specialist demonstrates excellent customer service performance in that his/her attitude and actions are at all times consistent with the standards contained in the Vision, Mission and Values of Covenant and the commitment to Extraordinary Care for Every Generation. The pre-certification Specialist coordinated pre-certification activities for scheduled patients by screening all elective admissions and procedures for appropriateness, looking at medical necessity and intensity of service. He/she performs authorization procedures for radiology testing and specific outpatient procedures. He/she maintains current database regarding payor requirements and authorization guidelines.
Demonstrates excellent customer service.
Contributes to organization success targets for patient satisfaction.
Contributes to organization success targets for net operating margin.
Ensures the availability of accurate and timely information.
Demonstrates age specific competency in the selected age groups: newborn, infant, pediatric, child, adolescent, adult, and geriatric.
Reviews documentation and works with physician/offices to assure that appropriate Patient Class is assigned prior to procedures.
Knowledgeable regarding Medicare ABN requirements, assists with issuing when appropriate.
Knowledge of Federal, State and Local government regulations as they relate to Precert and billing requirements.
Works collaboratively with Admitting, Scheduling, CBO, HIM, and Finance Department to optimize reimbursement.
Completes payor pre-notification / pre-certification to obtain approval authorization for scheduled surgical patients.
Acts as a final gatekeeper for CRM case management specialist on criteria application prior to elective patients receiving services at Covenant HealthCare.
Coordinates contact between physician and payors.
Manages and responds to concurrent third party payer denials of outpatient and inpatient cases alleged to be medically inappropriate..
Maintains an organized database of payor requirements and contracts.
Prepares, issues, distributes, and tracks notices of non-coverage.
Mentors Insurance Advisors and others on reimbursement requirements and strategies for success.
Keeps up to date of third party payor contracts and their requirements.
Works with the healthcare team to demonstrate fiscal responsibility by being conscious of the need to appropriately use the resource dollars available.
Maintains flexibility to changes in delivery of clinical information, i.e. electronic transfer.
Serves as a resource to the health care team related to denial management and utilization management.
Demonstrates excellent communication skills, negotiation skills, diplomacy and assertiveness.
Builds and nurtures professional, effective relationships with all members of the Healthcare team.
Manages conflict effectively, striving for win-win outcomes.
Serves as a liaison that interacts with physician office staffs and facilitates meetings with payers. Works to maximize positive outcomes.
RN with current license in State of Michigan required.
3 years clinical experience required
Successful performance in utilization management preferred.
Clinical experience with understanding of disease process and treatment regimens associated with designated patient populations.
Strong computer skills.
Excellent verbal and writing skills along with diplomacy, negotiation and assertiveness skills.
Critical thinking skills, analyzing multiple issues impacting outcomes.
Problem solving skills and the ability to manage many situation simultaneously. Able to adjust to priorities that may change minute by minute.
Strong commitment to collaboration and teamwork, with demonstrated ability to work as a member of a team where assignments must be coordinated with peers.
Has a solid understanding of the Healthcare industry, technology and regulations.
A professional approach to work, including a strong sense of responsibility for assigned duties.
WORKING CONDITIONS/PHYSICAL DEMANDS
Ability to maintain punctual attendance consistent with the ADA, FMLA, and other federal, state, and local standards.
Frequent standing, walking, sitting, talking, hearing and near vision.
Occasional lifting up to 100 lbs.
Occasional lifting, carrying, pushing, pulling, climbing, balancing, stooping, kneeling, crouching, squatting, crawling, twisting, reaching, handling, feeling, midrange vision, far vision, depth perception, visual accommodation, color vision and field of vision.
NOTICE REGARDING LATEX SENSITIVITY IN APPLICANTS FOR EMPLOYMENT.
It has been determined that Covenant HealthCare cannot provide a latex safe or latex free work environment at any of its facilities. Unfortunately, that means that any individual, including an applicant or an employee, is likely to be exposed to latex while on Covenant's premises. Therefore, latex tolerance is considered to be an essential function for any position with Covenant.
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