JOB SUMMARY: Performs and documents pre-certification from insurance companies for all elective surgeries, with some guidance.
Obtains certification from insurance companies for all elective surgeries and admissions.
Assigns preliminary diagnosis and procedure codes when required by insurance review companies for authorization.
Contacts insurance review agencies to request authorization.
Handles problematic certification cases with relevant internal groups.
Performs extensive investigative and follow-up work on cases with precertification issues until the issue is resolved.
Documents certification process in the appropriate applications to facilitate accurate concurrent review, billing and reimbursement.
The responsibilities listed are a general overview of the position and additional duties may be assigned.
INSURANCE REGULATORY KNOWLEDGE - Demonstrates knowledge of the appropriate rules and regulations for insurance policies, claims, payment and coverage. Ability to interpret and explain rules and regulations that are ambiguous or unclear.
CUSTOMER SERVICE - A continuing focus on the needs and requirements of customers, anticipating their needs, remaining sensitive to customers while performing services for them, responsive to customer needs.
DATA ENTRY - The ability to transcribe information from the original source into an electronic system according to written and verbal instructions efficiently and accurately.
PROBLEM SOLVING - Uses critical thinking and process improvement i.e. coaches and mentors development of problem statement, describes current state, identifies root causes, creates future state, coaches and mentors development of solutions and action plans with a sustainability plan. Applies appropriate tools to address issues.
CODING KNOWLEDGE - Ability to assign and interpret ICD-10-CM/PCS coding classification systems and MS-DRG and APR-DRG prospective payment and severity systems.
Organizational Impact: Delivers job responsibilities that impact own job area/team with some guidance.
Problem Solving/ Complexity of work: Uses existing procedures, research and analysis to solve standard job related problems that may require some judgement.
Breadth of Knowledge: Requires subject matter knowledge within a professional area to meet job requirements.
Team Interaction: Individually contributes to project/ work teams.
Vanderbilt University Medical Center is a comprehensive health care facility dedicated to patient care, research, and biomedical education. Our reputation for excellence in these areas has made us a major center for patient referrals from throughout the Mid-South. Each year, people throughout Tennessee and the Southeast choose Vanderbilt University Medical Center for their health care because of our leadership in medical science and our dedication to treating patients with dignity and compassion.The mission of Vanderbilt University Medical Center is to advance health and wellness through preeminent programs in patient care, education, and research.