The role of Precertification Intake Support is to determine the precertification requirement of upcoming medical/surgical procedures. Frontline professional staff members receive incoming calls from both members and providers and screen the requests to refer them to the medical services staff. They utilize reference tools to decide the need for notification and medical review, collate medical information, and assign length of stay for certain elective inpatient surgical procedures. They also pend cases that require medical review, identify cases for case management and disease management, and perform non-medical research including eligibility verification, coordination of benefits, and benefits verification. The output of this role is to authorize medical procedures/services or create cases for clinicians' review.
Job Description
Precertification Intake Support involves determination of precertification requirement of an upcoming medical/surgical procedure. It consists of frontline professional staff who take incoming calls either from members or providers
Front line staff accepts incoming calls from members or providers to determine precertification requirement for any medical and surgical procedure
- Screens requests in order to appropriately refer items to the medical services staff
- Utilizes reference tools to determine the need for notification and medical review
- Collates medical information and determines precertification review in accordance with the benefit plan
- Assigns length of stay based on approved reference tools for certain elective inpatient surgical procedures
- Pend cases that require medical review
- Appropriately identifies cases for case management and disease management
- Performs Non-medical research including eligibility verification, coordination of benefits and benefits verification
- OUTPUT: Medical procedures/ services authorized or cases created and sent to clinicians for review.
