Coordinates the clinical review and obtaining authorizations for the procedures performed in the SpineCare Center.  Requires attention to detail and the ability to work in multiple computer systems to verify insurance eligibility and determine requirements for precertification of insurance. 

1.  Reviews order report to initiate and obtain for pre-authorization and pre-certification
2. Utilizes insurance website and electronic fax to upload info needed for pre-authorization and pre-certification
3. Reviews Electronic Fax for all incoming pre-authorization and pre-certification to create the case for approvals in Expanse
4. Make appropriate changes to patient’s demographic and insurance information when needed
5. Verify that we have the correct contract and group number in system in order to obtain pre-authorization or pre- certification
6. Enters pre-authorization or pre-certification numbers into Expanse by creating the case along with documentation
7. Reviews clinical and non-clinical data which includes medical terms and diagnosis or procedure codes in order to obtain pre-authorization or pre-certification.
8. Has knowledge and understanding of insurance companies’ policies and criteria as related to pre-authorization and pre-certification.
9. Know CPT codes for procedures/drugs to make sure it does or does not require pre-certification or pre-authorization
10. Verify that we are in network or out of network in relationship to pre-authorization

DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.

• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.

• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.

All other duties as assigned

Can write legibly, speak and read English. Experience with obtaining pre-authorizations and working with insurance companies preferred. Medical Terminology preferred. High school graduate, good clerical abilities, Demonstrated proficiency in keyboarding/computer use. Self-motivated and the ability to work effectively in an independent environment. Ability to work well with the public, physicians, insurance companies and other hospital staff in a courteous and professional manner.  Healthcare experience required.  Must be able to read, write, and speak English.

WORKING CONDITIONS: 

Communication through talking, expressing and exchanging ideas by means of the spoken word. Working in a small area where conditions require sitting 80% of the time and standing, kneeling, squatting, walking, and stooping 20% of the time.  Is able to lift 35 pounds’ maximum.  Good manual and finger dexterity.  Hearing and vision must be corrected to within normal range.  Mental capability to always maintain patient confidentiality 100% of the time.

PHYSICAL FACTORS

• Must be able to perform the duties with or without reasonable accommodation.
• Hearing and vision must be normal or corrected to within normal range.
• Physical presence onsite is essential.

OTHER JOB FACTORS

Job requires orientation to detail, accountability and ability to interact with customers when the communication may be discourteous or unpleasant.