Job Position: Pre-Certification Specialist
Job Description: The purpose of the Pre-Certification Specialist is to obtain needed pre-certification or pre-authorization for all procedures and all referred outpatient testing. This job requires the application and interpretation of policies and procedures, an understanding of the need for and the ability to produce timely pre-certification, and the use of independent judgment in a medical office setting. The ability to maintain a working knowledge of carrier contracts/changes and medical necessity policies is required.
Job Type: Full-time
Pre- Certification Specialist
Receives information from the clinic staff at various times during the day, indicating the services or drugs a patient requires
Calls insurance companies to obtain pre-certification(prior authorization)
All documentation of prior authorization/pre-certification findings will be documented in current clinical software and following current clinic policy
Provide updates and feedback to the ASC, clinical, billing and scheduling teams as new information is learned related to payer requirements
Have a detailed understanding of the major plans and be able to identify procedures that require prior approvals
Use clinical knowledge, where necessary, to ensure prior-authorization/precertification meet clinical guidelines for approval. This may include speaking with a nurse or medical director of the insurance plan to explain clinical indicators meeting medical necessity of lab, diagnostic imaging, and/or surgical procedures
Check charts for current insurance and benefits verification
Works closely with the Reimbursement Department to identify trends related to authorization denials
Other duties as assigned
Ability to interact professionally and diplomatically with physicians, hospitals, insurance companies and coworkers.
Proficient computer skills.
Excellent communication skills, both verbal and written.
Strong organizational skills.
Ability to accurately & efficiently work in a fast paced environment
Maintain HIPAA confidentiality at all times.