JOB SUMMARY: Performs pre-certification for all elective surgeries for the department and/or clinics utilizing clinical information and pre-certification criteria. Responsible for communicating and collaborating with physician offices, UM, or supervisor regarding problematic certification cases. Documents certification process and certification number in the appropriate computer applications such as EPIC, Medipac, etc.
Obtains timely certification from insurance companies for all elective out-patient specialty surgeries for both the surgeon and the Facility using clinical information and based on pre-certification criteria.
Achieves timely pre-certification for elective surgical cases or admissions 100% of the time.
Utilizes all clinical records, including StarChart to efficiently obtain pertinent patient clinical information.
Utilizes ICD-9 and CPT coding resources to accurately assign with minimal or zero error preliminary diagnosis and procedure codes, when required by insurance review companies for authorization.
Contacts insurance review agencies by phone or fax or insurance company's web-sites to request authorization providing accurate and up-to-date clinical information with zero or minimal error.
Maintains and applies to daily work, a working knowledge of different pre-certification criteria used by insurance companies, utilizes criteria system in MCIS computer system and applies that knowledge during pre-certification process.
Handles problematic certification cases for the department and/or clinics through collaboration with physician office, UM and department supervisor.
Elevates to supervisor problem cases appropriately 100% of the Time.
Consults with supervisor and/or surgeon/designee when serious difficulties arise to review alternatives to surgery, and documents the outcome in the designated computer system with zero error.
Performs extensive investigative and follow-up work on cases with pre-certification issues until the issue is resolved.
Collaborates with IM dept staff and UM dept nurses if questions arise regarding pre-certification with zero or minimal error and provides assistance as needed to the UM and IM staff.
Effectively communicates and collaborates with physician or physician's office staff in the department and/or clinic to ensure timely and accurate certification is obtained.
Interacts with medical and professional staff, on a case-by-case basis, to obtain additional clinical documentation for assistance in obtaining certification with zero or minimal error.
Notifies physician or office staff with zero or minimal error when insurance referral or certification is incomplete or has not been obtained.
Communicates unsupported medical necessity cases based on review of criteria of insurance denials with physicians or designees. Facilitates next step of medical review or obtains pre-certification utilizing additional information from physician or designee. (i.e. facilitating peer to per reviews).
Serves as a resource to the physicians and office staff and interacts with patient and/or family regarding pre-certification procedures with zero or minimal error.
Collaborates with insurance companies and physicians to justify if Vanderbilt is sole provider for this procedure, in-network benefits when only out-of-network benefits are available.
Documents certification process and certification number information for both the physician and the facility correctly and timely in the appropriate computer applications such as EPIC, Medipac, etc. to facilitate accurate concurrent review, billing and reimbursement for the department, clinic, and/or Hospital Facilities.
Enters authorization number and days approved data into all computers systems to facilitate hospital billing and physician billing with zero or minimal error.
Enters clear, concise, real-time documentation in the department specific computer system, Medipac, and EPIC of all steps taken with insurance review agency and/or physician when authorization obtained or alternative settings/arrangements are required with zero or minimal error.
Maintains and updates computer applications daily in comparison to VORS reports in order to capture all surgeries for billing.
Coordination of payment for the physician and facility for self-pay patients (in-patient as well as out-patient surgeries).
Coordination of co-pays or monies to be collected from the patient for both the hospital and the physician. (this includes contacting the patient by phone or mail regarding the co-pays/deductibles).
Obtains referrals for initial Physical Therapy and Occupational Therapy appointments as necessary. Also verifies benefits for initial PT and OT appointments based on physician protocols.
Utilizes appropriate resources to obtain certification for the department or clinic out-patient surgeries.
Maintains knowledge of and uses the MCIS for insurance contract information, insurance plan descriptions and requirements, and in-service announcements.
Maintains knowledge and utilizes Insurance Company web-sites to obtain pre-certifications for out-patient elective surgeries.
Vanderbilt University Medical Center is home to Vanderbilt University Hospital, The Monroe Carell Jr. Children’s Hospital at Vanderbilt, the Vanderbilt Psychiatric Hospital and the Vanderbilt Stallworth Rehabilitation Hospital. These hospitals experienced more than 61,000 inpatient admissions during fiscal year 2015. Vanderbilt’s adult and pediatric clinics treated nearly 2 million patients during this same period.
Vanderbilt University Hospital and the Monroe Carell Jr. Children’s Hospital at Vanderbilt are recognized again this year by U.S. News & World Report’s Best Hospitals as among the nation’s best with 18 nationally ranked specialties.
Vanderbilt University Medical Center is world renowned because of the innovation, work ethic and collegiality of its employees. From our health care advances to our compassionate care, Vanderbilt owes its accomplishments and reputation to staff and faculty who bring skill and drive and innovation to the medical center day after day. World-leading academic departments and comprehensive centers of excellence pursue scientific discoveries and transformational educational and clinical advances across the entire spectrum of health and disea...se.
As the largest employer in middle Tennessee, we welcome those who are interested in ongoing development in a caring, culturally sensitive and professional atmosphere. Most of us spend so much of our lives at work, we want to be part of maintaining a workplace in which people support one another and encourage reaching for excellence. Many high-achieving employees stay at Vanderbilt because of the professional growth they experience and because of their appreciation of Vanderbilt’s benefits, public events and discussions, athletic opportunities, beautiful setting and, above all, sense of community and purpose.
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