What Does a Precertification Nurse Do?

Precertification involves an administrative process where a treatment plan is submitted by a healthcare provider, usually to an insurance company on behalf of a patient, before initiation of treatment to ensure the insurance company will cover the plan as submitted. This administrative process is often handled by experienced nurses — usually registered nurses, but sometimes licensed practical nurses are hired for the position as well. A precertification nurse will carry out a number of different tasks to complete this process. Such tasks include processing patient admissions and discharges, registering patients, verifying insurance, ensuring all documentation is available and in order, submitting treatment plans to insurance companies, and handling the appeals process when care is denied. Responsibility also includes communicating changes made to insurance programs and contracts when required.

Insurance companies often will require certain treatments and medications to be precertified before administering or dispensing to the patient. Medical providers are responsible for knowing which procedures and medication require precertification and for obtaining authorization before administering treatment. Nurses who work in precertification will therefore spend most of their time attending to paperwork, researching information online and in print, handling data entry of required information, and communicating with healthcare professionals, insurance companies and patients. The precertification nurse may also conduct end-of-month reconciliation between his or her patient’s accounts and insurance companies.

A precertification nurse will gather all required medical data from the patients attending medical professionals and the appropriate information from the patient regarding insurance coverage. Next, he or she will assign procedure codes to all treatment plans advised. Using Current Procedural Technology (CPT) and International Classification of diseases book 9 (ICD-9) codes, the precertification nurse will document all diagnostic procedures and ensure accuracy before submitting to insurance companies. Thereafter, he or she will determine what precertifications are required, fill-out and process the required precertification paperwork, and submit it to the insurance company for approval. Once approved, he or she will notify the attending medical professionals and the patient.

In the event treatment plans are denied, the precertification nurse will usually initiate the appeals process and manage that process through to completion. Coordination with the medical records staff is often central to the job to ensure patient medical records are up to date and reflect the outcome of the precertification process. Additionally, the role may also require applying payments issued by insurance companies to the correct patient accounts. Other expectations include prioritizing case loads, recognizing urgent cases, and processing cases quickly and efficiently, while following the healthcare providers proper protocols.