Precertification Nurse Coordinator (RN)

The Precertification Nurse Coordinator is responsible for collecting the required medical data and insurance information necessary for the precertification of elective inpatient and outpatient admissions and selected OP procedures.  The Precert Nurse Coordinator acts as a resource to the Authorization Specialist in the Precertification Department.

Reviews incoming Precert requests for completeness in EPIC.

• Evaluates and ensures diagnosis and procedures are classified correctly for place of service:  inpatient versus outpatient.
• Ensures diagnosis and procedure coding accurately reflects clinical information and procedures to be performed.
• Contacts physician offices to obtain detailed medical information as needed after review of Precert requests prior to calling third party payers (TPPs.)
• Update insurance info as needed in EPIC.
• Create HAR as needed in EPIC.
• Accurately documents pre-cert info in EPIC.

Demonstrates proficiency in disease physiology and keeps current with changes as they relate to procedures and treatments.

• Discuss disease physiology, past medical history and other pertinent health information in order to facilitate approval of admission.
• Consults Research/physician office/clinic in order to ensure accuracy of treatments/procedures before contacting TPP.

Collaborates with internal departments to ensure precertification is obtained in a timely and efficient manner.

• Obtains precertification for Cardiac, Hematology, Oncology, Critical Care, Endocrinology, Metabolism, Neurology, Rheumatology and other areas as assigned.
• Forwards non-par cases to be negotiated to the Manager of Special Care programs.  Ensures agreements have been negotiated prior to admission or service performed.
• Facilitates and obtains precertification prior to elective transfer from other acute care facilities.
• Precertifies critical care vent dependent patients for the Progressive Care Unit (PCU.)

Adheres consistently to changing third party payer criteria as it pertains to the hospital financial policy to ensure revenue capture.

• Obtains precertification according to TPP policy; meets requests for additional information in a timely manner.
• Coordinates the communication between physician offices and third party payers concerning contract exclusion and/or denials. 
• Denials are handled as per policy including follow up with the physician office regarding the denial.  Provides information regarding exceptions form. 
• Informs physician of correct procedure to follow when notification of TPP contract exclusion or denial of requested services is received.
• Refers self-pay patients to business office for payment options.

Interfaces with Case Management, Business Office and Bed Management to help maximize reimbursement.

• Researches and shares pertinent data with other departments, as necessary.

Functions independently and able to direct others in order to facilitate the smooth operation of the Precert Department.

• Assists PSA staff in interpreting clinical information, diagnoses and/or procedures.
• In the supervisor’s absence, prioritizes workload and delegates responsibilities to other staff members.
• Liaison with physician offices, as necessary in supervisor’s absence.

Required Education: Nursing Diploma

Required Experience:

• Two (2) years of experience in an acute pediatric hospital setting.

Preferred Education: BSN

Preferred Experience: One (1) year of utilization and/or precertification experience

• Ability to exercise judgment and react resourcefully under varying conditions
• Excellent communication skills and demonstrated organizational skills
• Must demonstrate professionalism to all internal and external customers
• Ability to complete multiple tasks and meet deadlines
• Ability to maintain confidentiality of patient information
• Computer literate
• Must be customer service oriented
• ICD 9 and CPT coding