Member Certification Specialist jobs in Cedar Falls, IA

Department: Clinic

Hours: Fulltime - Day Shift

Description:

JOB DUTIES & RESPONSIBILITIES:

Position Overview:

The Prior Authorization/Pre-certification and Referral Specialist is responsible for obtaining eligibility, benefits, authorizations, pre-certifications for the clinic setting. This role may also support and collaborate with the outpatient specialty clinic and hospital inpatient departments. This role will use telephonic and online support systems to complete insurance prior authorizations/pre-certifications, routine authorizations, and appeal denials.

This role will also manage all facets of the patient referral process for the clinic setting. The scope of the referral process begins with receipt from the provider through to the communication with the patient. Interacts in a customer-focused and compassionate manner to ensure patients and their representative needs are met. In addition to obtaining pre-certification or prior authorizations, responsibilities include scheduling the visit with specialist or outpatient services, completion of documentation in the patient record and communicating referral appointment information to the patient.

The Prior Authorization/Pre-certification and Referral Specialist must be a Certified Medical Assistant (CMA) or Licensed Practical Nurse (LPN). Performs CMA/LPN duties as needed based on staffing needs as determined by the Clinic Director. Must be able to perform all job duties and responsibilities as well as meet all qualifications of the Clinic CMA or LPN. Clinic CMA/LPN job description available upon request.

Duties:

• Prioritize incoming authorizations and specialist referral requests according to urgency
• Obtain authorization via payer website or by phone and follow up regularly on pending cases
• Maintain individual payer files to include up to date requirements needed to successfully obtain authorizations
• Initiate appeals for denied authorizations
• Respond to questions regarding payer medical policy guidelines
• Confirm accuracy of CPT and ICD-10 diagnoses in the procedure order
• Contact patients to discuss authorization or specialist referral status
• Other duties as assigned
  

QUALIFICATIONS:

• Excellent customer service skills
• Ability to communicate effectively
• Ability to multi-task and prioritize to meet deadlines
• Excellent computer skills including Excel, Word, and Internet
• Organization and attention to detail required
• Ability to work independently
• Basic understanding of human anatomy
• Medical terminology helpful
• Knowledge of procedure authorization and its direct impact on the practice’s revenue cycle
• Proficient use of CPT and ICD-10 codes

EDUCATION

Graduate of an accredited nursing program or medical assistant program

EXPERIENCE

• 2 years experience in a medical related field required
• 2 years medical prior authorization experience preferred

PHYSICAL REQUIREMENTS

• Able to speak clearly and distinctly with staff, patients, and families
• Able to hear to converse with others on the phone
• Able to stand/walk for extended periods of time throughout the work schedule, with some lifting and bending
• Demonstrates adequate vision to prepare and read documents accurately
• Demonstrates adequate stamina to deal with stressful situations and to complete the necessary work schedule
• Possess fine motor skills and hand-eye coordination to manage office equipment
  

Floyd County Medical Center Core Principles

Floyd County Medical Center (FCMC) Core Principles apply to every position and support FCMC’s primary value that the needs of our patients come first.

Continuously improves processes and services that support patient care, education, and research.

• Demonstrates patient-centered and customer focus by treating patients/customers as a top priority to meet or exceed needs and expectations.
• Contributes ideas and suggestions and participates in activities that improve systems, processes, and service for patients and customers.

Fosters mutual respect and supports FCMC’s commitment to diversity.

• Demonstrates mutual respect of individual differences by contributing to the recruitment, retention, and support of a diverse work force.
• Supports an inclusive work environment by communicating positively and effectively with a variety of people including patients, families, visitors, colleagues, and physicians regardless of race, color, religious creed, national origin, ancestry, age, gender, pregnancy, sexual orientation, gender identity, age, marital status, familial status, disability or genetic information.
• Treats others with dignity and contributes to a workplace free from harassment

Fosters teamwork, personal responsibility, integrity, innovation, trust, and communication.

• Exhibits an understanding of the roles and responsibilities of team members and recognizes individuals for their contributions.
• Contributes to the enhancement of group effectiveness by exchanging information, collaborating with other team members, and providing constructive feedback.
• Listens attentively to patients, families, visitors, colleagues, and physicians to ensure understanding and delivery of personalized service.
• Accepts feedback and uses it to improve service and individual and team performance.
• Helps develop team cohesiveness by offering assistance to team members and aligns individual work efforts to meet work unit and organizational goals for service excellence.

Maintains a patient-centered, positive, and helpful orientation when working with individuals within and outside of the department .

• Effectively manages emotions, including anger and frustration.
• Adjusts to change in a positive and supportive manner.
• Completes assignments on time, contributing extra effort to meet patients’, families’, visitors’, colleagues’, and physicians’ needs.

Adheres to high standards of personal and professional conduct.

• Adheres to patient confidentiality.
• Complies with all FCMC policies, procedures, department guidelines, and applicable laws in the conduct of routine activities and the solution of problems.
• Complies with FCMC’s attendance and punctuality policy (excludes absences related to Family Medical Leave).
• Performs activities in a manner that ensures a safe environment for patients, families, visitors, colleagues, physicians, and the public.
• Adheres to FCMC’s dress code and professional grooming standards.

Maintains and enhances professional/competency skills.

• Attends and participates in continuing education as appropriate to maintain and enhance professional knowledge and/or job skills.
• Attends and participates in all required medical center education programs (e.g. annual CareLearning updates).
• Attends and participates in all required department specific or job specific meetings.
  

Physical/Cognitive Requirements:

• Frequent sitting and remaining in stationary position for extended periods.
• Occasional standing and walking to move about office and buildings.
• Frequent reaching/handling/fingering to complete paperwork, use the phone and computer.
• Frequent talking, hearing, seeing to interact with staff, patients, visitors, etc.
• Occasional stooping/kneeling/crouching to access documents and supplies in lower cabinets.
• Occasional pushing/pulling of equipment and filing cabinet drawers weighing up to 20lbs
• Occasional lifting/carrying of supplies and equipment weighing up to 30lbs
• Moderate concentration/intensity, which includes prolonged mental effort with limited opportunity for breaks.
• Normal memory, taking into consideration the amount and type of information.
• Moderate level of complexity for decision making and time pressure of decision making.

The physical demands described here are representative of those that must be met to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Environmental Factors:

• Free from hazardous working conditions.
• The possibility exists of exposure to communicable disease due to working in a healthcare environment.
  

QUALIFICATIONS:

• Bachelor’s Degree in Business or related field preferred.
• Minimum of five years experience working in a revenue cycle environment preferred.
• Extensive knowledge of all Revenue Cycle functions preferred.
• Knowledge of ICD 10-CM and CPT coding guidelines preferred.
• Medical terminology course completion or previous work experience utilizing medical terminology required.
• Phone, typing, and computer skills required.
• Must have practical knowledge of common office software applications including Microsoft Windows, Outlook, Excel, Word, Edge, etc.
• Able to read, write, comprehend, and speak English.
• Able to use a computer frequently for extended periods of time.
• Able to read, write, comprehend, and speak English.
• Able to use a computer frequently for extended periods of time.
• Able to work flexible hours.