POSITION SUMMARY:

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.

SUPERVISORY DUTIES:

• None

POSITION REQUIREMENTS:

• 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

WORKING ENVIRONMENT:

1. 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%

Standing:                                                                              10%

2. 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.