Member Certification Manager jobs in West Virginia

To ensure procurement of accurate pre-certification authorization/referral for applicable returning and new patients as well as review and completion of accurate, complete patient charts. Scheduling of multiple physician ordered tests, exams and surgeries where applicable.

Responsibilities

• Daily review of charts to determine if pre-certification/pre-authorization or referrals are needed. • Review specific patient insurance info to determine medical necessity requirements for specific treatments. • Correspond with medicare and various insurance companies to facilitate obtaining pertinent data on compliance, authorizations, verifications, progress notes, medical necessity guidelines and precertification and pre-authorization requirements. • Perform clerical duties as necessary, including composing letters to patients, insurance carriers and referring physicians regarding any issues. • Per physician order, schedule patient surgery and communicate all necessary information to the appropriate parties. • Make subsequent referrals to other physicians per physician review of test/scan results. • Establish new patient account in billing software upon receiving referral from physician. Forward all applicable info to appropriate personnel for inclusion in the medical chart. • Maintain continuing education treatment trends, current medical terminology used in pre-certification, and ICD-10, CPT and HCPCS codes. • Cross train for front desk and medical assistant roles. Provide back up as needed. • Schedule all procedures, collect, apply and deposit all funds.

Knowledge, Skills & Abilities

Patient Group Knowledge (Only applies to positions with direct patient contact) The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment or care as defined by the department’s identified patient ages. Specifically the employee must be able to demonstrate competency in: 1) ability to obtain and interpret information in terms of patient needs; 2) knowledge of growth and development; and 3) understanding of the range of treatment needed by the patients. Competency Statement Must demonstrate competency through an initial orientation and ongoing competency validation to independently perform tasks and additional duties as specified in the job description and the unit/department specific competency checklist. Common Duties and Responsibilities (Essential duties common to all positions) 1. Maintain and document all applicable required education. 2. Demonstrate positive customer service and co-worker relations. 3. Comply with the company's attendance policy. 4. Participate in the continuous, quality improvement activities of the department and institution. 5. Perform work in a cost effective manner. 6. Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations. 7. Perform work in alignment with the overall mission and strategic plan of the organization. 8. Follow organizational and departmental policies and procedures, as applicable. 9. Perform related duties as assigned.

Education

• High School Diploma or GED

1 year of Healthcare experience required

Credentials

• No Certification, Competency or License Required

Work Schedule: Days

Status: Full Time Regular

Location: Doctor's Park Office Building

Location of Job: US:WV:Hurricane

Talent Acquisition Specialist: Tamara B. Young tammy.young@vandaliahealth.org