precertification representative

HCA Florida North Florida Hospital​

<div><h5 class="jobSectionHeader">Introduction</h5>
This Work from Home position requires that you live and will perform the duties of the position; within 60 miles of an HCA Healthcare Hospital (Our hospitals are located in the following states: FL, GA, ID, KS, KY, MO, NV, NH, NC, SC, TN, TX, UT, VA).
Experience the HCA Healthcare difference where colleagues are trusted, valued members of our healthcare team. Grow your career with an organization committed to delivering respectful, compassionate care, and where the unique and intrinsic worth of each individual is recognized. Submit your application for the opportunity below: Precertification Representative Work from Home<h5 class="jobSectionHeader">
Benefits</h5>
Parallon offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include:<ul><li>
Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation.</li><li>
Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more.</li><li>
Free counseling services and resources for emotional, physical and financial wellbeing 
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401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service) 
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Employee Stock Purchase Plan with 10% off HCA Healthcare stock 
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Family support through fertility and family building benefits with Progyny and adoption assistance. 
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Referral services for child, elder and pet care, home and auto repair, event planning and more 
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Consumer discounts through Abenity and Consumer Discounts 
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Retirement readiness, rollover assistance services and preferred banking partnerships 
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Education assistance (tuition, student loan, certification support, dependent scholarships) 
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Colleague recognition program 
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Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence) 
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Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income.</li></ul>
Learn more about Employee Benefits
Note: Eligibility for benefits may vary by location. 
We are seeking a Precertification Representative for our team to ensure that we continue to provide all patients with high quality, efficient care. Did you get into our industry for these reasons? We are an amazing team that works hard to support each other and are seeking a phenomenal addition like you who feels patient care is as meaningful as we do. We want you to apply!<h5 class="jobSectionHeader">
Job Summary and Qualifications</h5> 
The Precertification Representative is responsible for requesting, obtaining and following up on authorization requests. Requests and interdepartmental scheduling with minimal delay to customer. Correct utilization of all systems and accurately enters all mandatory information. Provides instructions to patients and physician&rsquo;s staff on authorization requirements and information. Establish and maintain a working knowledge and vocabulary of scheduled procedures. Manage daily operations including but not limited to: Meditech, Orders Management System, Call Center Equipment (phones, etc.), payer websites. 
In this role you will: 
<ul><li>
Requests, obtains and follows up on authorization requests
</li><li>Processes Phoned and/or faxed requests processed in a prompt and timely manner</li><li>
Stat requests and interdepartmental scheduling processed promptly;</li><li>
Contacts the facilities, physicians&rsquo; offices and/or insurance companies to resolve denials/appeals</li><li>
Schedules patient tests, and/or procedures in a prompt, courteous manner;</li><li>
Correctly utilizes the features of the Meditech system and accurately enters necessary information;</li><li>
Instructs patients and physician staff on authorization, test preparation and registration information;</li><li>
Establishes and maintains a working knowledge and vocabulary of procedures scheduled;</li><li>
Demonstrates the willingness and ability to process requests for diagnostic procedures and coordinates the Peer to Peer function as needs arise</li><li>
Checks patient orders for compliance with Medicare guidelines</li><li>
Processes physician&rsquo;s orders in accordance with department standards</li><li>
Assists with orientation of new employees as needed and serves as a resource within the department;</li><li>
Displays confidence when processing difficult or interdepartmental requests;</li><li>
Recognized by customers as knowledgeable and helpful</li></ul> 
Qualifications: 
<ul><li>
High school diploma or GED preferred.</li><li>
One year of precertification experience preferred</li><li>
Previous Call Center Experience preferred</li><li>
Meditech experience a plus</li><li>
Virtual Employees are required to have wired High Speed Internet Speed 25 MBS Download and15MBS Upload</li><li>
Remote employees are required to live within 60 miles of an HCA hospital.</li></ul>
Parallon provides full-service revenue cycle management, or total patient account resolution, for HCA Healthcare. Our services include scheduling, registration, insurance verification, hospital billing, revenue integrity, collections, payment compliance, credentialing, health information management, customer service, payroll and physician billing. We also provide full-service revenue cycle management as well as targeted solutions, such as Medicaid Eligibility, for external clients across the country. Parallon has over 17,000 colleagues, and serves close to 1,000 hospitals and 3,000 physician practices, all making an impact on patients, providers and their communities.
HCA Healthcare has been recognized as one of the World&rsquo;s Most Ethical Companies&reg; by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated $3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses. 

&quot;Good people beget good people.&quot;- Dr. Thomas Frist, Sr. 
HCA Healthcare Co-Founder
We are a family 270,000 dedicated professionals! Our Talent Acquisition team is reviewing applications for our Precertification Representative PRN opening. Qualified candidates will be contacted for interviews. Submit your resume today to join our community of caring!
We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.</div>

Precertification Representative PRN

LewisGale Regional Health System

HCA Houston Healthcare

Parkridge Health System

Medical City Healthcare

HMSA

<div>
 
 Employment Type
 
 
 
 Full-time
 
 
 
 Exempt or Non-Exempt
 
 
 
 Exempt
 
 
 
 Job Summary
 
 
 
 
 Hybrid Work Environment - Must reside in Hawaii
 
 
 
 
 Pay Range:
 
 $59,000 to $116,000
 
 
 
 Note
 
 : Individuals typically begin between the minimum to middle of the pay range
 
 
 Under minimal supervision, conducts detailed analysis and review of precertification requests, post-service and suspended claims, by applying clinical expertise against HMSA medical and reimbursement policies, plan benefits and nationally accepted clinical guidelines to determine appropriateness of care for all HMSA lines of business.
 
 
 
 Minimum Qualifications
 
 
 
 <ul>
 <li>
 Associates degree in Nursing.
 </li>
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 Current, unrestricted Nursing License in the state of Hawaii as an RN or LPN.
 </li>
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 Two years clinical, case management or utilization management related experience.
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 Knowledge of current standards of care to be followed for a given diagnosis and the normative values of medical tests and procedures.
 </li>
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 Strong organizational skills
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 Good communication skills both verbally and written
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 Analytical skills
 </li>
 <li>
 Basic knowledge of Microsoft Office applications. Including but not limited to Word, Excel, and Outlook.
 </li>
 <li>
 Currently licensed in Hawaii as an RN or LPN
 </li>
 <ul>
 <li>
 (if applicable upon hire, proof of licensure to be provided by employee or confirmed by Human Resources)
 
 </li>
 </ul>
 </ul>
 
 Duties And Responsibilities
 
 
 
 <ul>
 <li>
 Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
 </li>
 <ul>
 <li>
 Demonstrate understanding and application of over 250 Guide to Benefits, Evidence of Coverage, Plan Brochure, and Member Handbook. HMSA annually updated medical and drug policies, medical protocols, National Comprehensive Cancer Network, Milliman Care Guidelines, Drugdex, etc. to determine the medical necessity of urgent and non-urgent precertification requests. Urgent requests must be completed within 72 hours and non-urgent requests within 15 calendar days.
 </li>
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 Use clinical judgment, medical necessity guidelines and plan benefits to determine approval, potential denial or alternative treatment of each urgent or non-urgent precertification request. Settings include inpatient, outpatient, in-state, out-of state and out-of country.
 </li>
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 Document clinical case summary and review outcome of each review appropriately to meet regulatory and program requirements.
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 Review various types of services, including but not limited to:
 </li>
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 Transplants
 </li>
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 Air Ambulance
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 Chemotherapy
 </li>
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 Clinical trials
 </li>
 <li>
 Genetic testing
 </li>
 <li>
 Cancer treatments/radiation therapy
 </li>
 <li>
 Experimental/Investigational Services/Devices
 </li>
 <li>
 New Technology
 </li>
 </ul>
 <li>
 Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
 </li>
 <ul>
 <li>
 Call providers when additional clinical information is required to clarify or complete a complex precertification determination.
 </li>
 <li>
 Approve precertification requests based on clinical judgment using criteria, medical record documentation and other information received from the provider.
 </li>
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 Consult with Medical Directors on requests which do not meet clinical criteria and offer alternative covered health care options as appropriate.
 </li>
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 Consult Medical Directors on potential quality issues identified during review of medical records. Refer cases to Integrated Health Management, Pharmacy Department or Benefits Integrity Department depending on the concern.
 </li>
 </ul>
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 Evaluate suspended claims against medical records to determine the medical necessity and appropriateness of medical services, identify irregularities such as over or under-utilization of services, potential up-coding, over billing, etc.
 </li>
 <li>
 Communicate timely, accurate information either verbally, electronically or in writing using clinical judgment, knowledge of medical/reimbursement policies and plan benefits to providers, members as well as internal MM staff and other internal departments (Claims Administration, Customer Relations, Provider Contracting, etc.). For denied services, ensure the denial, benefit and appeal language are accurate and consistent with department procedures, accreditation and regulatory guidelines.
 </li>
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 Identify and refer members with specific medical and/or behavioral health needs or complex case management and collaborate with medical and behavioral case management staff. Identify and refer quality of care issues and suspected fraud, waste or abuse to the appropriate departments.
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 Perform pre-screening assessment of incoming pre-certification requests to ensure appropriateness of review. Advises non-clinical staff on clinical and coding questions to ensure correct system processes and entries.
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 Performs all other miscellaneous responsibilities and duties as assigned or directed.
 
 
 </li>
 </ul>
</div>

Nurse Reviewer - Clinical Review Unit

Ballad Health

<div>Job Description: 
Summary: 
The Patient Service Representative (PSR) greets all patients and visitors in a courteous and friendly manner and registers the patient according to Ballad Health processes. The duties of the PSR may include, but are not limited to: updating and scheduling patient appointments, retrieving daily patient data for appointments and phone calls, maintaining provider(s) schedules, filing charts/medical records, copying charts/forms, pulling charts, purging charts, producing documents for providers to sign, collecting co-pays, performing data entry of office visit charges, performing collections of unpaid balances, coding encounter forms with proper payment distribution CPT &amp; ICD-10 codes, filing and refiling insurance claims, reconciling the charge sheet, counting the cash drawer, preparing bank deposits, balancing credit cards, reviewing and correcting errors on the missing ticket report, performs closing procedures to ensure proper account balance, perform referral and precertification and prepares information for audit purposes.
Requirements: 
Required &ndash; High School diploma or equivalent; previous experience performing data entry and utilizing data base. Ability to maintain patient confidentiality/HIPAA. Ability to communicate respectfully/kindly with patients, office staff, nurses, and medical staff 
Preferred &ndash; Knowledge of CPT and ICD-9 codes/billing. Previous experience utilizing Electronic Health Record (EHR) system. 
 
 
 
Work Requirements: 
Shift: Day 
On Call: No 
Weekends: No 
Travel Required: No Travel 
Shift Details: 8-5PM
 
City/State: Gray, TN
Location: 
Ballad Health Medical Associates</div>

Patient Service Representative (8a-5p) - Gray, TN

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Patient Service Representative (8a-5p) - Gray, TN