Pre Cert Specialist CIV in Houston, TX at Parallon

Date Posted: 3/18/2018

Job Snapshot

  • Employee Type:
  • Location:
    8101 West Sam Houston Parkway South
    Houston, TX
  • Job Type:
    Health Care
  • Experience:
    Not Specified
  • Date Posted:

Job Description

Job Summary – The Pre- Certification Specialist will review all post discharge and or prebill accounts that do not have an authorization on file.  Daily review of all LOS versus days authorized variances, and/or other account discrepancies identified that will result in the account being denied by the payer and that require additional clinical expertise.  Communicates with third party payers to resolve discrepancies prior to billing and is responsible for accurately and concisely documenting all communications and actions that have occurred for the account in accordance with policies and procedures.  Ensures that escalation for medical review request and/or denial activities to management team occur on a timely basis to escalate reimbursement and reduce further delays and or denials of claims.
Supervisor – CIV Manager
Supervises N/A
Functional areas:

•       Obtain authorizations for post discharge, prebill accounts

•       Perform re-certification for additional days on post discharge, prebill accounts

•       eRequest/ Passport queues as determined during program implementation
Duties (included but not limited to):

•       Work retro Medicaid and prebill accounts efficiently and effectively obtaining authorizations for entire length of stay.

•         Evaluates clinical documentation on multiple patient accounts and escalates issues through the established chain of command

•       Perform accurate and timely documentation of all review activities based on policy and procedure

•         Demonstrates a working knowledge of managed care agreements based on available resources which may include and not be limited to payer UM Manual, policy and procedure, facility contract information. Escalates variations timely.

•       Work assigned accounts in eRequest to resolve outstanding issues

•       Report insurance denial trends identified during daily operational assignments

•       Contact facilities, physicians’ offices and/or insurance companies to resolve denials/appeals if needed

•       Demonstrates knowledge of regulatory requirements, Ethics and Compliance policies, and quality initiatives; monitors self-compliance and implements process changes to ensure compliance to such regulations and quality initiatives.

•       Communicates effectively and professionally with physicians, hospital staff, and outside agencies

•       Adhere to all policies and procedures, including, attendance, phone and internet usage, break utilization, etc.

•       Participate in education and training as needed

•       Establish and maintain relationships with all customers

•       Seeks assistance from immediate supervisor when in situations which are unclear or ambiguous

•         Adheres to established policy and procedure and standards of care; escalates issues through the established Chain of Command timely

•       Demonstrates commitment to teamwork and cooperation

•       Practice and adhere to the “Code of Conduct” philosophy and “Mission and Value Statement”

•       Other duties as assigned

Knowledge, Skills & Abilities

•         Customer Orientation – establishes and maintains long term customer relationships, building trust and respect by consistently meeting and exceeding expectations

•       Communication - communicates professionally, clearly and concisely

•       Interpersonal skills – ability to establish and maintain collaborative and effective working relationships

•       PC Skills – demonstrates advanced proficiency in Microsoft Office applications and others data mining software

•         Policies & Procedures - demonstrates knowledge and understanding of organizational policies, procedures and systems

•         Basic skills – demonstrates ability to organize, perform and track multiple tasks accurately in short timeframes and have ability to work quickly and accurately in a fast-paced environment while managing multiple demands

•         Clinical skills – ability to read/ interpret medical record documentation and present the clinical data obtained in an organized, concise dialogue to the payor in order to obtain auth and/or resolve other issues.

Job Requirements


•       Associate’s Degree or higher preferred

•       Utilization Review, appeals, denials, managed care contracting, experienced preferred