Pre-Certification Specialist

Job Description

Job Description

Role Overview

Pre-Certification Specialist oversees the process of obtaining prior authorizations. This process includes collecting all necessary documentation, and contacting facilities, physicians and / or staff for additional information. It also involves communication with a member or patient. Ability to quickly determine whether the order will likely be approved based on documentation and submitting the request via online portal or over the phone to insurance. This position may also be responsible for obtaining cost estimates, for the necessary approvals to be made as well as collecting pre-payments from patients. Able to work in an environment that may be stressful at times with the ability to meet firm deadlines.

Qualifications

High School graduate or GED equivalent

Minimum of 3 years of experience in Medical or Insurance field

Medical billing / coding knowledge required

Understanding of CPT and DX codes, specifically related to the Spine (preferred)

Prior Pre-Certification experience preferred

Essential Duties :

The following list describes the essential duties of this role. Individuals in this role may not perform all of thes duties, or may perform additional or unrelated duties

• Verify patient eligibility and review benefits
• Verify all codes are reviewable benefits
• Review codes and submit prior authorization request
• Review and submit clinicals documentation
• Follow through with obtaining the prior authorization
• Coordinate Peer-to-Peer review when needed
• Submit Appeals
• Collect pre-payments when applicable
• Submit retro-authorizations when applicable
• Meets department production standards consistently as defined by the department management
• Perform all duties respectful of confidentiality and safety of all patients, employees, and providers
• Requires working knowledge of HIPAA Privacy Rules compliance

Minimum Qualifications