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We strive to be an employer of choice and establish a reputation for being a talent rich organization where Associates can grow their career caring for others. For over a century, we’ve served the health care needs of the people of Memphis and the Mid-South.
Supervises and coordinates the work activities of the Authorization Specialists. Provides guidance, support, and direction to the department. The incumbent is also responsible for precertification of eligible medical services and procedures for diagnostic and outpatient services. Ensures complete documentation is obtained that meets insurer guidelines for medical necessity and payment for services. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.Working at MLH means carrying the mission forward of caring for our community and impacting the lives of patients in every way through compassion, a deliberate focus on service expectations and a consistent thriving for excellence.
A Brief OverviewSupervises and coordinates the work activities of the Authorization Specialists. Provides guidance, support, and direction to the department. The incumbent is also responsible for precertification of eligible medical services and procedures for diagnostic and outpatient services. Ensures complete documentation is obtained that meets insurer guidelines for medical necessity and payment for services. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.
What you will do- Supervises day to day departmental operations and processes of the pre-certification department. Provides guidance, support and direction to the department and staff.
- Assists staff with the understanding and implementation of policies and procedures to increase the overall efficiency of the department.
- Actively monitors and oversees the quantity of diagnostic and surgical procedures to ensure efficiency of precertification.
- Works with associates in complex pre-certification cases, ensuring protocols are followed and reimbursements are maximized.
- Works with payers to resolve technical problems and keep up with communications to eduate the team on changes that may affect reimbursement and precerts.
- Coordinates all documentation submitted by medical providers to evaluate the necessity, appropriateness and efficiency of the use of medical procedures.
- Establishes a good working relationship with physicians, physician office staff, patients, and other members of the healthcare team.
- Plans and schedules work ensuring distribution of assignments and adequate staffing based on workload and productivity standards.
- Monitors Associates performance and clarifies work expectations, assists with goal setting, and promotes cooperation among individuals and groups.
- Maintains and develops a competent, productive, and quality conscious workforce by hiring, evaluating performance, counseling, training, issuing corrective action, and recommending promotion or discharge of department personnel according to the MLH value system.
- Develops and implements processes through orientation, training and education to ensure that the competence of all staff members is assessed, maintained, improved and demonstrated throughout their employment.
- Participates in the preparation of the capital budgets for assigned area(s), monitors and authorizes expenditures within budget limits. Assists in the development and implementation of capital budget and plans to control costs and improve department operations.
Education/Formal Training Requirements- Required - Technical Degree or Diploma Nursing
Work Experience Requirements- Required - Authorization or Denials Management 5-7 years
- Required - Clinical nursing 5-7 years
- Required - Precertification 5-7 years
- Preferred - Case Management 5-7 years
- Preferred - Lead, Supervisory, or Management
Licenses and Certifications Requirements- Required - Licensed Practical Nurse - Tennessee - Tennessee Board of Nursing
Knowledge, Skills and Abilities- Proficient in Microsoft Office such as Word and Excel.
- Extensive knowledge in insurance coverage practices, terminology, and requirements for referrals and authorization/pre-certification used by third party payers, Medicare, and secondary payer rules.
- Experience working with pre-certification and/or CPT medical codes.
- Demonstrated analytical ability to collect and interpret insurance and contract information. Uses clinical knowledge to effectively manage pre-certifications for more complex surgical and invasive procedures.
- Experience dealing with PPO and Managed Care insurance.
- Strong attention to detail and critical thinking skills. Ability to make decisions based on clinical knowledge/practices.
- Experience with a computerized healthcare information system required. Familiarity with fundamental Microsoft word software
- Excellent verbal and written communication skills.
- Demonstrates leadership abilities, judgment and supervisory skills in organizing work, assigning staff and making exceptions to policy.
Supervision Provided by this Position- Supervises Authorization Specialists in the department.
Physical Demands- The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion.
- Must have good balance and coordination.
- The physical requirements of this position are: light work - exerting up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently.
- The Associate is required to have close visual acuity to perform an activity, such as preparing and analyzing data and figures; transcribing; viewing a computer terminal; or extensive reading.
- The conditions to which the Associate will be subject in this position: The Associate is not substantially exposed to adverse environmental conditions; job functions are typically performed under conditions such as those found in general office or administrative.
Our Associates are passionate about what they do, the service they provide and the patients they serve. We value family, team and a Power of One culture that requires commitment to the highest standards of care and unity.
Boasting one of the South's largest medical centers, Memphis blends a friendly community, a thriving and growing downtown, and a low cost of living. We see each day as a new opportunity to make a difference in the lives of the people in our community.
