Pre-Cert Specialist

If you are looking to make an impact on a meaningful scale, come join us as we embrace the Power of One!

We strive to be an employer of choice and establish a reputation for being a talent rich organization where Associates can grow their career caring for others. For over a century, we’ve served the health care needs of the people of Memphis and the Mid-South.

Responsible for problem solving methodologies and coordinating and monitoring prior authorizations for all aspects of patient care that pertain to hospital pre-admission and all levels of scheduled outpatient services to monitor health care services that are deemed necessary, appropriate, effective and cost efficient according to the guidelines set forth by the insurance carrier. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.

Working at MLH means carrying the mission forward of caring for our community and impacting the lives of patients in every way through compassion, a deliberate focus on service expectations and a consistent thriving for excellence.

A Brief Overview
Responsible for problem solving methodologies and coordinating and monitoring prior authorizations for all aspects of patient care that pertain to hospital pre-admission and all levels of scheduled outpatient services to monitor health care services that are deemed necessary, appropriate, effective and cost efficient according to the guidelines set forth by the insurance carrier. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.

What you will do

• Responsible for precertification of eligible medical services and procedures for inpatient, diagnostic, and outpatient services based on medical plan documents and medical necessity. Manages pre-certifications for more complex surgical and invasive procedures that require strong clinical knowledge.
• Reviews clinical information submitted by medical providers to evaluate the necessity, appropriateness and efficiency of the use of medical procedures. Expertise in clinical knowledge of invasive procedures, and demonstrates understanding of medical procedures and equipment use.
• Coordinates all documentation required for precertification of services. Ensures medical documentation is sufficient to meet insurer guidelines for medical necessity documentation and procedure payment. Performs research regarding denials or problematic accounts as necessary. Works to identify trends and root cause of issues and recommend resolutions for future processes.
• Establishes a good working relationship with physicians, physician office staff, patients, and other members of the healthcare team.
• Notifies physician office and/or patient when services are not approved. Follows process and protocols for appeals and precertification decisions. Documents and codes accounts in Cerner according to established procedures
• Understands, applies, and supports departmental/hospital policies, procedures, and standards.
• Actively participates in problem solving methodologies; identifies and communicates areas for improvement in ongoing efforts for quality care; assists in gathering, analyzing and presenting data in the assigned populations.

Education/Formal Training Requirements

• Associate's Degree Nursing- RN
• Bachelor's Degree Nursing- RN

Work Experience Requirements

• 5-7 years General nursing or clinical practice

Licenses and Certifications Requirements

• Accredited Case Manager (ACM) American Case Management Association Certification
• Case Manager - The Commission for Case Manager Certification
• Registered Nurse Arkansas - Arkansas State Board of Nursing
• Registered Nurse Mississippi - Mississippi Board of Nursing
• Registered Nurse Tennessee - Tennessee Board of Nursing

Knowledge, Skills and Abilities

• Advanced knowledge and experience in coverage practices, terminology, and requirements for referrals and authorization/pre-certification used by third party payers, Medicare, and secondary payer rules.
• Experience working with pre-certification and/or medical codes.
• Demonstrated analytical ability to collect and interpret insurance and contract information. Clinical knowledge to effectively manage pre-certifications for more complex surgical and invasive procedures.
• Experience dealing with PPO and Managed Care insurance.
• Strong attention to detail and critical thinking skills. Ability to make decisions based on clinical knowledge/practices.
• Experience with a computerized healthcare information system required. Familiarity with fundamental Microsoft word software
• Excellent verbal and written communication skills.

Supervision Provided by this Position

• There are no lead or supervisory responsibilities assigned to this position.

Physical Demands

• The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion.
• Must have good balance and coordination.
• The physical requirements of this position are: medium work - exerting up to 50 lbs. of force occasionally and/or up to 25 lbs. of force frequently.
• The Associate is required to have close visual acuity including color, depth perception, and field of vision to perform an activity, such as assessing patients, preparing and analyzing data and figures; transcribing; viewing a computer terminal; or extensive reading.
• Frequent non-invasive patient contact.
• Exposure to patient body fluids as well as exposure to hazardous or poisonous materials.
• Ability to react quickly to emergency situations.

Our Associates are passionate about what they do, the service they provide and the patients they serve. We value family, team and a Power of One culture that requires commitment to the highest standards of care and unity.

Boasting one of the South's largest medical centers, Memphis blends a friendly community, a thriving and growing downtown, and a low cost of living. We see each day as a new opportunity to make a difference in the lives of the people in our community.