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


Qualifications

  1. Ability to interact professionally and diplomatically with physicians, hospitals, insurance companies and coworkers.

  2. Proficient computer skills.

  3. Excellent communication skills, both verbal and written.

  4. Strong organizational skills.

  5. Ability to accurately & efficiently work in a fast paced environment

  6. Maintain HIPAA confidentiality at all times.