Job Description

Join Carolina Pines Regional Medical Center, a 116-bed community hospital located in Hartsville, SC, that has been recently honored with ScionHealth’s Platinum Award, eight consecutive “A” safety grades from Leapfrog, Top General Hospital honors from Leapfrog, and recognition as a Great Community Hospital by Becker's Hospital Review. The hospital delivers excellence across the continuum of services, and holds numerous accreditations and certifications in areas that include chest pain, stroke and heart failure, hip and knee replacement, sepsis, and more. Come grow your career at Carolina Pines, where innovation, safety, and community are core to everything we do.

Job Summary

The Pre-Cert and Referrals Clerk is responsible for obtaining prior authorizations for all procedural orders by successfully completing the authorization process with all commercial payers.

Essential Functions

• Schedules outpatient diagnostic tests and referrals as ordered by the providers. Documents the tests and referrals in Athena.
• Maintains knowledge of insurance carrier requirements. Organizes and provides all necessary information to obtain the necessary authorization or precertification from the insurance carriers.
• Works with the referring provider to resolve insurance denials or requests for additional information.
• Notifies patients of their scheduled appointments. Documents their acknowledgement.
• Performs other general administrative tasks as directed by the team lead.
• Verifies the order with electronic and paper pre-certification data by matching reports.
• Contacts insurance carriers to downgrade or upgrade pre-certs.
• Reviews claim denials.
• Verifies the completeness and accuracy of coding. Use resources such as the CPT and ICD-9 provider manuals, Medicare’s Correct Coding Initiative, subscriptions, and publications to support correct coding.
• Contacts insurance carriers to verify the status of claims and resolve processing problems.
• Appeals claim denials as justified.
• Identifies problem payers and reports them to the Assistant Practice Administrator.
• Documents all insurance follow-up activity in.
• Participates in educational activities.
• Maintains strictest confidentiality.
• Looks for trends of denials and reasons for those denials to minimize lost revenue.
• Maintains and updates list of insurance carriers and companies.
• Monitors changes in the insurance industry and notifies office staff of those and polices.
• Performs related work as required.
• Other duties as assigned.

Knowledge/Skills/Abilities/Expectations

• Requires critical thinking skills, decisive judgement, and the ability to work with minimal supervision.
• Must be able to work in a stressful environment and take appropriate action.

Qualifications

Education

• High School Diploma or Equivalent including education equivalent to completion of secondary school or demonstrated ability to perform the essential functions of the role. AND Postsecondary (Cert/Diploma/Program Grad) vocational or specialized training (Preferred)

Licenses/Certifications

• None Required

Experience

• 2 years medical prior authorization/referrals experience preferred.
• 2 years of experience in a medical related field required.