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Insurance Precertification Registered Nurse

Philadelphia, PA, US, 19107

Job Type: 

Req ID: 24907

Shift: Days

Employment Status: AF - Active - Regular - Full Time 

Job Summary

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.

Job Responsibilities

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 Licenses, Certifications, Registrations

RN - PA

Required Education and Experience

Required Education: Nursing Diploma

 

Required Experience:

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

Preferred Education, Experience & Cert/Lic

Preferred Education: BSN

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

Additional Technical Requirements

  • 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

All CHOP employees who work in a patient building or who provide patient care are required to receive an annual influenza vaccine unless they are granted a medical or religious exemption.

Children's Hospital of Philadelphia is committed to providing a safe and healthy environment for its patients, family members, visitors and employees. In an effort to achieve this goal, employment at Children's Hospital of Philadelphia, other than for positions with regularly scheduled hours in New Jersey, is contingent upon an attestation that the job applicant does not use tobacco products or nicotine in any form and a negative nicotine screen (the latter occurs after a job offer).

Children's Hospital of Philadelphia is an equal opportunity employer. We do not discriminate on the basis of race, color, gender, gender identity, sexual orientation, age, religion, national or ethnic origin, disability or protected veteran status.

VEVRAA Federal Contractor/Seeking priority referrals for protected veterans.  Please contact our hiring official with any referrals or questions.

CHOP Careers Contact 

Talent Acquisition

2716 South Street, 6th Floor

Philadelphia, PA 19146 

Phone: 866-820-9288 

Email:TalentAcquisition@email.chop.edu

 

 

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