The Precertification Specialist is responsible for obtaining prior authorizations for all procedural orders by successfully completing the authorization process with all commercial payers.
ESSENTIAL POSITION FUNCTIONS:
- Receives the necessary insurance and surgery scheduling information from the surgery coordinators for patients scheduled for surgery. Includes information from all insurance plans except Coventry and CMO’s.
- Places a call to the insurance company customer service office to pre-certify CPT codes along with an ICD9 code requested by the physician for surgical procedures.
- Checks insurance eligibility and benefits on patients scheduled for surgery.
- Informs the surgery coordinator if there is a change in insurance coverage or benefits and obtains new information from the insured so that it can be entered into our system.
- Opens a case number for insurances requiring a pre-cert, or patient eligibility and benefits are verified for. This will allow the reimbursement department to bill the surgery codes.
- Precertifies all diagnostic tests such as MRI’s CT scans, Sleep Studies, pH Probes, Airway Fluoroscopies, etc.
- High school education or G.E.D. equivalent
- At least one year of experience in a surgical medical practice is preferred
- Working knowledge of CPT and ICD9 coding
- Possesses the knowledge and experience to understand insurance terms and requirements for precertification
- Understands medical terminology, types of diagnostic tests, and surgical procedures
- Strong oral and written communication skills
- Physical Demands:
Lifting Requirements: 0-20 lbs.
Frequency of Lifting 0-15% of the time
The average percent of the time during a regular shift devoted to:
Walking, Squatting, Sitting, Bending, Reaching: 90%
- Visual, Hearing, Dexterity, and Mental Demands:
Vision: Adequate to perform the essential functions of the job such as read a computer terminal for long periods. Correctable to 20/20
Hearing: Adequate to perform the essential functions of the job such as answering the telephone
Speaking: Adequate to perform the essential functions of the job such as communicating via telephone
Dexterity: Adequate to perform the essential functions of the job such as sorting papers, stapling, operating a computer keyboard and other office equipment.
Mental Demands: Adequate to perform the essential functions of the job such as communication with insurance plan representatives, reimbursement staff and parents. Must be able to handle a fair amount of stress.