Precert Specialist

The PreCertification Specialist is responsible for supporting the Medical Director, Director of Health Services, PreCertification Case Manager, and the Supervisor of Health Services. Responsibilities include assuring above standard health care services are available to Bravo members in an appropriate cost-effective manner and delivery of those services emphasize preventive care and promote healthy outcomes.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Accurate completing of data entry into the Health Services software systems.
• Verification of member and provider eligibility.
• Process approval and adverse determination correspondence for members, contracted and non-contracted providers with appropriate oversight.
• Clear appropriate and concise documentation of information received.
• Adherence to regulatory and departmental timeframes for review of requests received.
• Notifies member and providers of all clinical determinations.
• Activates and maintains filing and tracking systems of approval and adverse clinical determinations.
• Provides excellent customer service to internal and external providers while answering phones.
• Completes review of non authorized medical claims.
• Proficient knowledge of Health Services policies and procedures.
• Proficient knowledge of Medicare and HIPPA regulations and NCQA standards.
• Must be proficient in data entry with minimal errors.
• Professional demeanor and the ability to work effectively within a team and independently.
• Flexible with the ability to multi- tasks and shift priorities upon urgency.
• Attendance and Punctuality above standard.
• Other duties as requested.

EDUCATION and/or EXPERIENCE:

• High School Diploma or equivalent.
• 1-3 years experience in a managed care environment, hospital setting or physician’s office preferred.
• Must be proficient in medical terminology, CPT and ICD-9 coding
• Certification in medical terminology, coding or equivalent certification preferred.