Pre-Certification Specialist

Join to apply for the Pre-Certification Specialist role at Michigan Medicine

3 days ago Be among the first 25 applicants

Join to apply for the Pre-Certification Specialist role at Michigan Medicine

Get AI-powered advice on this job and more exclusive features.

How to ApplyA cover letter is required for consideration for this position and should be attached as the first page of your resume. The cover letter should address your specific interest in the position and outline skills and experience that directly relate to this position.Job SummaryThe Precertification staff perform clinical reviews on all scheduled short stay and inpatient admissions to the hospital. The precertification review process includes the application of diagnosis and procedure codes and the interpretation and extraction of pertinent clinical documentation to support medical necessity criteria and level of care determinations. The precert team obtains authorizations for services based on our level of care decisions, preliminary coding and payer requirements. The Precertification staff work closely with a variety of internal and external customer including but not limited to clinical areas, medical providers, insurance companies, admitting, case management and revenue cycle.Mission StatementMichigan Medicine improves the health of patients, populations and communities through excellence in education, patient care, community service, research and technology development, and through leadership activities in Michigan, nationally and internationally. Our mission is guided by our Strategic Principles and has three critical components; patient care, education and research that together enhance our contribution to society.Why Join Michigan Medicine?Michigan Medicine is one of the largest health care complexes in the world and has been the site of many groundbreaking medical and technological advancements since the opening of the U-M Medical School in 1850. Michigan Medicine is comprised of over 30,000 employees and our vision is to attract, inspire, and develop outstanding people in medicine, sciences, and healthcare to become one of the world’s most distinguished academic health systems. In some way, great or small, every person here helps to advance this world-class institution. Work at Michigan Medicine and become a victor for the greater good.What Benefits can you Look Forward to?

• Excellent medical, dental and vision coverage effective on your very first day
• 2:1 Match on retirement savings

Responsibilities*

• Coordinate and conduct pre-admission reviews for all scheduled and urgent (non-same day) admissions and short stays. Determine appropriate level of care based upon clinical review, medical necessity criteria and institutional patient placement guidelines.
• Assign ICD-10 and CPT codes for planned procedures/treatment and provide to payers as required. Utilize preliminary codes to identify procedures requiring inpatient status or procedural authorizations to assure accurate reimbursement.
• Evaluate all patient payment sources, verify insurance eligibility, collect insurance benefit information and determine insurance referral and authorization requirements based on level of care determination.
• Complete all aspects of the pre-authorization process and negotiate the appropriate level of care for patient services within required timeframes. Extract pertinent clinical information from the electronic health record and provide to payers utilizing payer specific communication protocols.
• Initiate interventions when criteria is not met and initiate follow up actions as needed. Coordinate peer to peer reviews between attending, physician advisors and medical directors at the insurance company when appropriate. Coordinate, initiate and follow through on preadmission appeals on behalf of Michigan Medicine, the providers and patients until case approved or all appeal options are exhausted.
• Identify and communicate issues related to level of care determinations and prior authorizations to the appropriate clinical areas. Refer potential patient liabilities to the patient business services areas per established guidelines.
• Conduct admission and discharge reviews for the Obstetric-Labor and Delivery population of patients admitted to the hospital. Obtain inpatient authorizations as needed and follow the patient encounter until mom and well-baby are discharged, ensuring all payer requirements are met. Maintain workqueues and patient lists, update the patient class as appropriate and follow-up on OB admission claims issues until resolution when needed.
• Clearly and thoroughly document all actions, contacts, outcomes and interventions to assure appropriate payment of claims.
• Provide and discuss authorization status information to patients when appropriate
• Inform physicians and clinical staff on the aspects of medical necessity criteria and payer requirements.
• Obtain retro authorizations on billed and rejected claims and denied procedure codes for facility and professional services. Initiate appropriate follow-up actions in response to information obtained and document outcomes for appeals as needed.
• Attend and participate in operational meetings, utilizing LEAN thinking and principles. Develop standard processes and incorporate efficiencies into daily workflow.
• Assist and contribute to the overall achievement of the Michigan Medicine and Revenue Cycle’s quality, operational and financial goals and objectives.

Required Qualifications*

• An Associate’s degree in Health Information Technology, Healthcare Administration, or other healthcare related field and/or current Professional Coding Certification (CPC) with 2-3 years of healthcare experience is necessary.
• Experience working with insurance companies and third party payers is required.
• Ability to assess and extract appropriate clinical information from a patient’s medical record is necessary.
• Strong written and interpersonal communication skills, problem solving, decision making and negotiation skills are required.
• Must have demonstrated ability to work well with physicians, other healthcare providers and co-workers.
• Excellent computer application skills are required.
• Strong dedication to customer service, ability to be flexible and work within a team-focused, participative management framework is required.

Desired Qualifications*

• A Bachelor’s Degree and prior experience working in Precertification, Coding, Health Information Management or Utilization Review is strongly desired.
• Knowledge of Interqual and/or MCG criteria and government insurance regulations is recommended.
• Understanding and ability to interpret medical terminology and insurance benefit information is preferred.

Work LocationsThis position is a remote position where you will work from home/virtually once training is completed and performance-based competency has been obtained. High speed internet is a requirement for this position and the cost is the responsibility of the staff member. There may be occasions where the staff member may need to report to the business office location, including meetings, computer or technology requirements, or to complete work that is not possible to handle remotely. The business location will have space available to reserve onsite work when required or necessary. Although there is some flexibility in working hours, the business location and operations are in the Eastern Time Zone and work hours must accommodate interactions, including video conferencing, with colleagues during these hours. Computing resources including required software applications, VPN, desktop or laptop computer, monitor, webcam, keyboard and mouse, will be provided by the employer. Remote staff are not provided with a mobile phone but are provided with computer telephone and fax technology. Office equipment such as desk, chair, and printer are not provided. Basic supplies such as paper and pens, are stocked at the business location and are available to remote staff for pick-up should they choose. Unless otherwise agreed in advance with your manager, additional hardware, software, printing, and cost of office supplies preferred by the staff member, are the responsibility of the employee.Technology Skills required include the ability to set-up computer and monitors and connect accessory items such as mouse, keyboard, and web cams. Remote computing support is available 24/7 via phone, chat, or ticketing system, to all staff members. Staff will be expected to effectively communicate and resolve most computing issues directly with computing support resources.Modes of WorkPositions that are eligible for hybrid or mobile/remote work mode are at the discretion of the hiring department. Work agreements are reviewed annually at a minimum and are subject to change at any time, and for any reason, throughout the course of employment. Learn more about the work modes.Background ScreeningMichigan Medicine conducts background screening and pre-employment drug testing on job candidates upon acceptance of a contingent job offer and may use a third party administrator to conduct background screenings. Background screenings are performed in compliance with the Fair Credit Report Act. Pre-employment drug testing applies to all selected candidates, including new or additional faculty and staff appointments, as well as transfers from other U-M campuses.Application DeadlineJob openings are posted for a minimum of seven calendar days. The review and selection process may begin as early as the eighth day after posting. This opening may be removed from posting boards and filled anytime after the minimum posting period has ended.U-M EEO StatementThe University of Michigan is an equal employment opportunity employer.

Seniority level

• Seniority level

  Entry level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Information Technology

• Industries

  Hospitals and Health Care

Referrals increase your chances of interviewing at Michigan Medicine by 2x

Sign in to set job alerts for “Certification Specialist” roles.

Certification and Data Management Specialist

Legal Services National Technology Assistance Project (LSNTAP) - Administrative Coordinator

Ann Arbor, MI $45,000.00-$50,000.00 4 days ago

Departmental Technician E9 - Staffing Office WRPH-Child and Adolescent Services

Document Processing Intermediate Associate

Ann Arbor, MI $32,860.00-$39,436.00 2 days ago

On-Call Registration/Answer Center Support (Applicant Pool)

Department Administrator (Performance Analysis and Materials)

Contract & Operations Support - Brighton, MI

Ann Arbor, MI $47,000.00-$47,000.00 2 days ago

Team Support Specialist - Waiver Support

Full Time Scheduler (Southeastern Michigan)

Ann Arbor, MI $40,400.00-$50,500.00 2 weeks ago

We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.

#J-18808-Ljbffr

apply to this job