Lead Pre-certification Coordinator

Scope of Position

The Lead Pre-certification Coordinator is responsible for coordinating and managing pre-testing processes and activities within the OSU Sleep Disorder Center including precertification/prior authorization. This position contributes to the day-to-day operations of the sleep disorder center and adheres to OSUWMC policies and procedures, including the organizations compliance program. This role involves a range of administrative, operational, and technical functions to ensure the smooth and efficient operation of the sleep lab while providing exceptional support to both patients and staff. The ideal candidate will possess strong organizational skills, attention to detail, and the ability to manage multiple tasks effectively.

Position Summary

An essential member of the OSU Sleep Disorder Center, this role ensures authorizations for outpatient testing, ambulatory and/or inpatient services are obtained before services are rendered. The successful completion of tasks performed by this position directly impacts denials and reimbursement from third party payers. This role is skilled in patient/physician relations, registration, scheduling, precertification and denials processes.

The Lead Pre-Certification Coordinator utilizes Relationship-Based Care to guide professional practice and embraces the Medical Centers mission, values, and standards by providing positive customer relations and achieving goals consistent with Key Results Areas which includes endorsing the organizations compliance program, maintaining infection control standards and implementing patient safety protocols as necessary.

In keeping with the mission, vision, and value statements, participation in volunteer activities for the community and professional organizations is highly encouraged and supported.

Duties and Responsibilities

60% Pre-Testing and Post-Testing Coordination

• Oversee the receipt and processing of physician orders for sleep studies.
• Perform prior authorizations for sleep studies to ensure that all required approvals are in place before testing.
• Coordinate with central scheduling, research, and direct referral physicians to schedule patient appointments for in-lab sleep studies.
• Verifies and allocates insurance plans utilizing electronic eligibility tools, phone calls payer, accesses web portals and initiates appropriate action for services including non-covered and out-of-network insurance services
• Submits timely electronic and verbal notifications and clinical documentation in accordance with contractual requirements and payer guidelines; coordinates with operations and clinical counterparts to obtain and submit necessary information and documentation
• Communicates potential issues, Service with Authorization guidelines to notify providers of pending authorizations/denials and peer to peer requests; escalates encounters per policy
• Effectively communicates utilizing telephone, emails, or correspondence for internal and external customers; understand when and how to escalate cases that require operations and leadership attention to initiate appropriate action
• Maintains up-to-date knowledge of computer applications, insurance/government regulations, managed care guidelines and Revenue Cycle policies/procedures used within the department.
• Handle patient inquiries and provide information regarding testing procedures, preparation, and follow-up.
• Reporting results to direct referral ordering providers and patients.
• Process and manage patient charges and billing information.

20% Schedule/Volume Management:

• Review and access future schedules to monitor patient volumes and ensure accuracy in the scheduling of in-lab day and night sleep studies.
• Communicate with Physicians regarding processing and finalizing studies to ensure results to patient and referring physicians in a timely manner.
• Adjust schedules as needed to optimize patient flow and resource utilization.

10% Technical and Operational Support:

• Coordinate and provide aid with the overall operations of the Sleep Disorders Center.
• Assist department leaders with the maintenance of highly specialized equipment. This includes working closely with IT department to troubleshoot any technical issues.
• Work with supporting departments that are involved in daily operations of the department.
• Cover on call rotation with management and lead techs for urgent off hour issues.

5% Project Management

Initiate and complete special projects and studies within designated timelines. Demonstrate strong organizational skills as they relate to prioritizing tasks and presentation of key elements for each project. Demonstrate and apply the ability to involve key personnel to meet project objectives. Effectively and consistently communicates project status to all involved parties through project Completion.

5% Other

Other duties as assigned by manager.

For Hire: Minimum requirement is high school diploma or general education degree (GED). AASM or RPSGT credentials preferred or associates degree or higher in Healthcare Administration, Medical Office Management, or related field preferred. Workable knowledge in medical terminology is required. Strong computer skills in areas of data mining and data analysis are desired. Coding certification is desired.

Experience: Minimum of 4 years of experience in a medical office or healthcare setting, with prior experience in a sleep center or similar environment preferred.

On going: Keeping up with an updated knowledge of HCPCS and CPT Coding guideline as it relates to job functions. Coding certification is preferred.