Pre Certification Coordinator

This position is responsible for coordinating clinical review requests based on benefits, appropriate-ness, and use of national criteria.

• Take incoming telephone calls from members, providers, hospitals, or primary care physicians.
• Receive Faxed or written referral requests for clinical review.
• The Pre-Certification Coordinator performs triage, process intake information, checks eligibility and coverage, and assesses the callers needs; everything from a simple referral for a diagnostic assessment to a need for immediate action, referral to case management, or Medical Director. This position does not make clinical review decisions.
• Provides assistance to process Level 3 Clinical Medical Review with collecting clinical documentation to support appropriate use of national criteria.
• Ensures the organization revise all clinical information for Level 3 Medical Director reviews.
• Ensures compliance with and/or adheres to Company HIPAA policies and procedures.
• Ensures the integrity of data entered into Company systems and/or database.
• Ensures Program Integrity for Fraud/Abuse and Exclusions.
• Ability to safely and successfully perform essential job functions consistent with the ADA, FMLA, and other federal, state, and local standards, including meeting qualitative and/or quantitative productivity standards.
• Ability to maintain reasonably regular, punctual attendance consistent with the ADA, FMLA, other federal, state, and local standards, and company attendance policies and procedures.
• Ability to come to work and work the regular schedule and shift for the position.
• Compliance with all personnel policies and procedures.
• Perform related duties as assigned.

Other Duties

• Take incoming telephone calls from members, providers, hospitals, or primary care physicians.
• Receive Faxed or written referral requests for clinical review.
• The Pre-Certification Coordinator performs triage, process intake information, checks eligibility and coverage, and assesses the callers needs; everything from a simple referral for a diagnostic assessment to a need for immediate action, referral to case management, or Medical Director. This position does not make clinical review decisions.
• Provides assistance to process Level 3 Clinical Medical Review with collecting clinical documentation to support appropriate use of national criteria.
• Ensures the organization revise all clinical information for Level 3 Medical Director reviews.
• Ensures compliance with and/or adheres to Company HIPAA policies and procedures.
• Ensures the integrity of data entered into Company systems and/or database.
• Ensures Program Integrity for Fraud/Abuse and Exclusions.
• Ability to safely and successfully perform essential job functions consistent with the ADA, FMLA, and other federal, state, and local standards, including meeting qualitative and/or quantitative productivity standards.
• Ability to maintain reasonably regular, punctual attendance consistent with the ADA, FMLA, other federal, state, and local standards, and company attendance policies and procedures.
• Ability to come to work and work the regular schedule and shift for the position.
• Compliance with all personnel policies and procedures.
• Perform related duties as assigned.