RN(REGISTERED NURSE) PRECERTIFICATION ANALYST

ADN Healthcare

NOW HIRING! RN PRECERTIFICATION ANALYST outside of Columbus, OH

Job Type: Direct

Are you considering a career change? Looking for a smaller community(25K population), that offers a low cost of living(18% lower than US average) and plenty of activities in the area but is within an hour of a large city. If so, an opportunity to work with an integrated health care system based in east central Ohio is looking for someone to join their team.

The system is a not-for-profit and has over 300 physicians and multiple outpatient care centers throughout the area.

The system is the largest provider in a six county region and a primary referral center.

It offers a higher level of service than what is typically found in a community of its size including open-heart surgery, trauma care, a Level II neonatal intermediate care unit, neurosurgery and
comprehensive cancer services.

They are proud of their rich history of serving the community and vow to continue the tradition of healing and caring with compassion, trust, innovation and excellence.
 
SUMMARY:

The Precertification Analyst obtains and/or verifies demographic, clinical, financial and insurance information.

The incumbent conducts online insurance eligibility/benefit verification, pre-certification/authorization, referral clearance and financial education on designated cases.

As appropriate, the incumbent notifies patient/guarantor and collects patient liabilities, and refers appropriate cases to resource counseling for follow-up and consultation, including the entry of patient/guarantor information in the patient accounting system.

Duties/Responsibilities:

  • -Performs financial clearance including pre-certifications for inpatient and outpatient patient types as well as other services.
  • -Performs insurance eligibility/benefit verification, utilizing a variety of mechanisms (EDI transactions, web access and by calling payers) and documenting information within the patient accounting system
  • -Determines the benefits and need for appropriate service authorizations (pre-certifications, 3rd party authorizations, referrals) and contacts the physician and case management/utilization review personnel, as necessary.
  • -Validates medical necessity (LMRP/LCD review) of Medicare and Non-Medicare cases to ensure clinical and financial clearance.
  • -Contacts scheduling and/or ancillary department staff for clarification, if cases require clarification of diagnosis and/or tests/procedures.
  • -Helps to insure patient is placed in the correct status according to CMS’s inpatient only procedure list.
  • -Communicates with patients, family members/guarantors, 3rd party payers, and physicians/office staff in the deployment of key activities
  • -Prepares special reports as directed by the manager to document utilization of the pre-service unit's services and patient flow.
  • -Provides assistance to other departmental personnel as needed.
  • -Cross-trains in various functions as needed to assist in the smooth delivery of departmental services.
  • -Maintains a working knowledge of applicable Federal, State, and local laws and regulations, the hospital organizational integrity program, standards of conduct, as well as other policies and procedures in order to ensure adherence.
EDUCATION/REQUIREMENTS:
  • Current Ohio RN License.
  • At least one (1) year of experience performing insurance verification and/or pre-certifying procedures.
  • Must have a strong familiarity with current ICD-9, ICD-10 and CPT codes.
  • Experience in clinical patient care setting desired.
  • Working knowledge of medical terminology, anatomy and physiology, and basic computer skills are high desirable.
  • Must possess excellent verbal and written communication skills in dealing with internal and external customers.
  • Accuracy, attentiveness to detail, time management and problem solving skills are mandatory traits.
  • Excellent organizational and time management skills with ability to handle multiple priorities simultaneously.
  • Must be comfortable operating in a collaborative, shared leadership environment.
  • Must possess a personal presence that is characterized by a sense of honesty, integrity, and caring.
ADDITIONAL INFO:
  • The facility is located east of Columbus.
  • The position is 36hrs/week day shift.
  • Person needs to have authorization, case management and utilization type of experience and could come from a doctors office as well.
  • The range is between $23.85 - $32.83 depending on experience and they offer a full benefit package.