Pre-Certification/Authorization Coordinator

Job Profile Summary

This role focuses on activities related to revenue cycle operations such as billing, collections, and payment processing.  In addition, this role focuses on performing the following Patient Access duties: Performs the administrative and financial-clearance duties necessary to facilitate the procurement of clinical services by patients. Collects patient's necessary demographic and financial information from physician offices, acute-care entities, or the patients themselves, schedules services for patients, and handles referrals from primary care doctors to ensure patients are scheduled for recommended appointments/procedures, etc.    An organizational related support or service (administrative or clerical) role or a role that focuses on support of daily business activities (e.g., technical, clinical, non-clinical) operating in a “hands on” environment.  The majority of time is spent in the delivery of support services or activities, typically under supervision.  An entry level role that typically requires little to no prior knowledge or experience, work is routine or follows standard procedures, work is closely supervised, and communicates information that requires little explanation or interpretation.

Job Overview

This role focuses on activities related to revenue cycle operations including, but not limited to billing, collections, cost estimates and payment processing.  In addition, this role focuses on performing the following Patient Access duties: Performs the administrative and financial-clearance duties necessary to facilitate the procurement of clinical services by patients. Collects patient's necessary demographic and financial information from physician offices, acute-care entities, or the patients themselves, schedules services for patients, and handles referrals from primary care doctors to ensure patients are scheduled for recommended appointments/procedures, etc.  An organizational related support or service (administrative or clerical) role or a role that focuses on support of daily business activities (e.g., technical, clinical, non-clinical) operating in a “hands on” environment.  Most of the time is spent in the delivery of support services or activities, typically under supervision.  An entry level role that typically requires little to no prior knowledge or experience, work is routine or follows standard procedures, work is closely supervised, and communicates information that requires little explanation or interpretation. 

Minimum Qualifications:

1. High school diploma or equivalent

2. Two (2) years of related experience in a hospital, physician office, or financial services

Preferred Qualifications:

1. Associate’s degree

2. Five (5) years of related experience in a hospital, physician office, or financial services

Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list.  Other duties and responsibilities may be assigned.

1. Contacts insurance companies, and workers compensation carriers to obtain verification of insurance, eligibility, and level of benefits.  Enters benefit information into hospital electronic medical record system.

2. Contacts patients, when necessary, for updates of financial and demographic information.  Ensures timely updates in EMR.

3. Obtains financial data from a variety of sources including both in-state and out-of-state payers.  Utilizes computer systems, payer eligibility sites & phone outreach.    

4. Arranges for coordination of benefits when more than one insurance carrier is involved.   

5. Seeks administrative approval of admission (precertification) for surgeries, admissions, procedures, imaging, and all other in-scope services by providing clinical data to payers.  Enters precertification information and proper documentation into hospital computer systems.    

6. Identifies procedures & services that are not covered services by individual insurance policies. 

7. Communicates all identified financial risk concerns to the ordering department and Patient Access leadership for immediate review and resolution. 

8. Collaborates with Financial Coordination and Pre-Registration colleagues regarding patients with identified financial risk concerns for resolution prior to services being rendered.

9. Obtains all applicable clinical documentation when required by insurance payers for elective services and submits information to payers within a timely and secured manner. 

10. Closely follows case statuses and communicates and/or documents in hospital system, pending and approved statuses within a timely manner. 

11. Immediately identifies denied claims and works closely with department leaders, coordinators and clinical team members toward their appeal and peer to peer workflow. 

12. Monitors productivity and quality of workflow directly, reaching days out, productivity, and quality review goals. 

13. Acts as a resource to other departments of the hospital regarding precertification policies and resolution of accounts including providing documentation records to assist with insurance appeals if a denial is received.

15. Maintains collaborative, team relationships with peers and colleagues to effectively contribute to the working group’s achievement of goals, and to help foster a positive work environment. 

16. Works closely with Case Management and Admitting colleagues to confirm level of care changes, particularly for unplanned or urgent admissions, and communicates level of care upgrades or downgrades with payers within a timely manner.  

17. Learns and adapts new workflow changes and updates as they occur in real-time and maintains an openness to updated workflows.  

18. Assists in the training and shadowing of new team members. 

Physical Requirements:

1.Frequent sitting, occasional standing & walking, and lifting of 5-10 lbs.  

2.A valid driver’s license is required for local travel to remote hospital sites, and the like. 

3.Mental requirements will be intense at times with involvement in many concurrent multi-faceted projects.

4. Requires manual dexterity using fine hand manipulation to operate a computer keyboard or related equipment

5. Requires ability to see computer screen, monitoring equipment and reports. 

Skills & Abilities:

1. Knowledge of medical terminology. 

2. Knowledge of ICD-10 and CPT coding.   

3. Thorough working knowledge of insurance, payer precertification requirements for in-network, out-of-network, Medicare, and Medicaid.  

4. Knowledge and willingness to learn computer systems (Microsoft Word/Excel). 

5. Strong verbal and written communication skills.  Must demonstrate a patient service focus.   

6. Excellent organizational skills, ability to prioritize work assignments, and attention to detail. 

7. Ability to respond effectively to changing priorities and work processes.   

8. Ability to work independently and participate in teams within the department and hospital. 

9. Strong customer services skills including excellent interpersonal and telephone skills. 

10. High degree of tact is necessary due to frequent interaction with patients, physicians, and insurance companies. 

11. Knowledge and understanding of health care delivery systems with special emphasis on the referral management process for managed care providers. 

At Tufts Medicine, we want every individual to feel valued for the skills and experience they bring. Our compensation philosophy is designed to offer fair, competitive pay that attracts, retains, and motivates highly talented individuals, while rewarding the important work you do every day.

The base pay ranges reflect the minimum qualifications for the role. Individual offers are determined using a comprehensive approach that considers relevant experience, certifications, education, skills, and internal equity to ensure compensation is fair, consistent, and aligned with our business goals.

Beyond base pay, Tufts Medicine provides a comprehensive Total Rewards package that supports your health, financial security, and career growth—one of the many ways we invest in you so you can thrive both at work and outside of it.

Pay Range: