Pre-Certification Nurse (5035)

JOB SUMMARY

Responsible for ensuring referrals and precertification are completed according to established protocol. The Precertification Nurse will primarily be responsible for obtaining precertification for procedures or testing requiring precert, communicating to patients, external medical offices and internal staff regarding policies and guidelines, and conducts daily investigations to validate insurance eligibility.

Key Job Responsibilities

Essential Function

Verifies payer sources for patients deemed appropriate for procedures and/or testing requiring precerts.

Responsible for submitting pertinent clinical data to pay along with ICD10; HCPCS; DRG if required.

Provides education and information to medical and clinical staff as well as patients and family.

Maintains patient medical records; documents patient status and care given. Utilizes patient computer systems to enter and retrieve data.

Confers and works collaboratively with patient/family/hospital staff regarding all aspects of patient needs in a customer responsive and courteous manner, in compliance with iRESPECT Standards and promoting patient/customer satisfaction.

Completes required continuous training and education, including department specific requirements.

• Maintains professional credentials and education necessary to keep abreast and maintain a current knowledge of precertification and clinical principles, concepts and techniques, best practices and current trends.
• Attends staff meetings, all mandatory in-service and additional continuing education as required.
• Contributes to the annual review of unit-based scope statement and determination of important aspects of care for clinical review.
• Assists in the development of indicators, thresholds, study methods, and data collection as assigned.
• Responds to problems/opportunities to improve care.
• Supports and is involved in the organization’s Performance Improvement initiatives.
• Participates in and maintains competencies required for the position.

Provides professional clinical care in accordance with patient care policies and procedures, demonstrated competencies, and with consideration given to risk management, infection control practices, and patient safety practices. Utilizes computer to enter and retrieve medical/patient information; generate statistics, computations, tables or charts. Maintains confidentially of all information in accordance with hospital, HIPAA, compliance and other regulatory requirements.

Maintains a clean, orderly, safe environment for patients and personnel. Adheres to established policies, compliance/quality improvement, and safety, environment and infection control standards.