We are urgently seeking a Pre-Certification Specialist is to join a large healthcare organization. As the mid-year starts, this organization is very busy, and they need YOUR help take advantage of an office setting position with a full-time schedule, a competitive salary, and be a Pre-Certification Specialist is with one of the fastest-growing Healthcare organization in the US. Get in NOW, while there is still huge room for growth and career development!
The Pre-Certification Specialist is responsible for supporting the Precertification Nurse, Medical Director and Director of Health Services by collecting, interpreting and evaluating medical information received for authorization. The Pre-cert Specialist will communicate with internal and external providers regarding authorization status.
Essential Duties and Responsibilities:
· Receive request for authorization from hospitals, providers, members and vendors; Meet service level goals (e.g., Grade of Service, Average Handle Time, Average Speed to Answer, abandonment rate).
· Determine authorization requirements based on company policy, member benefit grid and provider status.
· Review authorization requests and make determinations on correct authorization process (i.e. auto approve, refer to Precert Nurse or Medical Director).
· Maintain benchmark standards for TAT (Turn Around Time) as established by the organization.
· Provide determinations on authorizations request to members and/or providers based on benchmark standards for authorization decisions. Process extensions of authorizations as appropriate.
· Processes denials including correspondence sent to families, members, facilities and applicable contracted providers
· Notifies responsible parties prior to initiation of denial letter and ensures that member and responsible party understand details of the letter and the appeals processes to follow
· Completes review of non authorized medical claims
· Proficient knowledge of departmental policies and procedures; knowledge of Medicare, HIPPA and NCQA ;
· Professional demeanor and the ability to work effectively within a team or independently;
· Flexible with the ability to shift priorities when required;
· Maintains regular and acceptable attendance at such level as is determined at the employer’s sole discretion
· Must be proficient in medical terminology, CPT and ICD-9 coding
· Excellent interpersonal and communications skills with nursing staff, physicians, nurse practitioners and other health workers involved in the care of a member
· Able to work in a dynamic, fast-paced team environment and to promote team concept
· Substantial knowledge of Microsoft Office including SharePoint, Outlook, PowerPoint, Excel and Word
Should you be interested in this Pre-Certification Specialist position, please click the Apply button
Electronic Medical Record
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Long Term Care
Maintain Patient Confidentiality