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Job Requirements

·         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

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Pre-Certification Specialist

Confidential Birmingham, AL Full-Time
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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! 

Position Summary:

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

Skills required

Electronic Medical Record
Nursing
Diseases And Disorders
Long Term Care
Maintain Patient Confidentiality
Administer Medication

Location

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Pre-Certification Specialist
Estimated Salary: $74K
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