The Precertification staff perform clinical reviews on all scheduled short stay and inpatient admissions to the hospital. The precertification review process includes the application of diagnosis and procedure codes and the interpretation and extraction of pertinent clinical documentation to support medical necessity criteria and level of care determinations. The precert team obtains authorizations for services based on our level of care decisions, preliminary coding and payer requirements. The Precertification staff work closely with a variety of internal and external customer including but not limited to clinical areas, medical providers, insurance companies, admitting, case management and revenue cycle.
- Coordinate and conduct pre-admission reviews for all scheduled and urgent (non-same day) admissions and short stays. Determine appropriate level of care based upon clinical review, medical necessity criteria and institutional patient placement guidelines.
- Assign ICD-10 and CPT codes for planned procedures/treatment and provide to payers as required. Utilize preliminary codes to identify procedures requiring inpatient status or procedural authorizations to assure accurate reimbursement.
- Evaluate all patient payment sources, verify insurance eligibility, collect insurance benefit information and determine insurance referral and authorization requirements based on level of care determination.
- Complete all aspects of the pre-authorization process and negotiate the appropriate level of care for patient services within required timeframes. Extract pertinent clinical information from the electronic health record and provide to payers utilizing payer specific communication protocols.
- Initiate interventions when criteria is not met, including referral to the physician advisor and initiate follow up actions as needed. Coordinate peer to peer reviews between attending, physician advisors and medical directors at the insurance company when appropriate. Coordinate, initiate and follow through on preadmission appeals on behalf of Michigan Medicine, the providers and patients until case approved or all appeal options are exhausted.
- Identify and communicate issues related to level of care determinations and prior authorizations to the appropriate clinical areas. Refer potential patient liabilities to the patient business services areas per established guidelines.
- Conduct admission and discharge reviews for the Obstetric-Labor and Delivery population of patients admitted to the hospital. Obtain inpatient authorizations as needed and follow the patient encounter until mom and well-baby are discharged, ensuring all payer requirements are met. Maintain workqueues, update the patient class as appropriate and follow-up on OB admission claims issues until resolution when needed.
- Clearly and thoroughly document all actions, contacts, outcomes and interventions to assure appropriate payment of claims.
- Provide and discuss authorization status information to patients when appropriate
- Inform physicians and clinical staff on the aspects of medical necessity criteria and payer requirements.
- Obtain retro authorizations on billed and rejected claims and denied procedure codes for facility and professional services. Initiate appropriate follow-up actions in response to information obtained and document outcomes for appeals as needed.
- Attend and participate in operational meetings, utilizing LEAN thinking and principles. Develop standard processes and incorporate efficiencies into daily workflow.
- Assist and contribute to the overall achievement of the Michigan Medicine and Revenue Cycle’s quality, operational and financial goals and objectives.
- An Associate’s Degree in a health related field or Coding Certification and 2-3 years’ experience in a healthcare setting is necessary.
- Ability to assess and extract appropriate clinical information from a patient’s medical record is necessary.
- Strong written and interpersonal communication skills, problem solving, decision making and negotiation skills are required.
- Must have demonstrated ability to work well with physicians and other healthcare providers.
- Excellent computer application skills are required.
- Strong dedication to customer service, ability to be flexible and work within a team-focused, participative management framework is required.
- Prior experience working in Precertification, Coding, Health Information Technology, Utilization Review or Nursing is strongly desired.
- Knowledge of Interqual and/or Milliman criteria, third party payers and government regulations is recommended.
- Understanding and ability to interpret medical terminology and insurance benefit information is preferred.
Michigan Medicine conducts background screening and pre-employment drug testing on job candidates upon acceptance of a contingent job offer and may use a third party administrator to conduct background screenings. Background screenings are performed in compliance with the Fair Credit Report Act.
Michigan Medicine improves the health of patients, populations and communities through excellence in education, patient care, community service, research and technology development, and through leadership activities in Michigan, nationally and internationally. Our mission is guided by our Strategic Principles and has three critical components; patient care, education and research that together enhance our contribution to society.
Job openings are posted for a minimum of seven calendar days. This job may be removed from posting boards and filled anytime after the minimum posting period has ended.
U-M EEO/AA Statement
The University of Michigan is an equal opportunity/affirmative action employer.