Purpose
The Precertification Specialist is responsible for the completion of precertification, prior authorization, and notification for third‑party and government payers for all scheduled outpatient procedures and diagnostic testing. The Precertification Specialist communicates with insurance companies, clinic staff, outside physician offices, facilities, and patients to ensure authorizations are obtained in a timely manner.
Accountabilities and Job Activities
- Prioritize and process incoming authorization requests / orders.
- Review clinical documentation to extract pertinent information supporting medical necessity.
- Obtain patient benefit and eligibility status for pending procedures.
- Communicate effectively with payers and third‑party utilization management companies to achieve positive outcomes.
- Identify payer trends and provide feedback to the Billing Team Supervisor and providers.
- Appeal denied authorizations when warranted.
- Initiate peer‑to‑peer reviews and prepare documentation packets for the provider.
- Maintain understanding of payer medical policies and guidelines.
- Manage work queues, emails and phone messages timely and effectively.
Develop and Maintain Personal and Professional Skills
Attend all mandatory staff meetings per year unless excused.Attend mandatory in‑services and a minimum of two pertinent in‑services per year.Actively participate in performance improvement activities as observed or documented.Establish realistic professional goals as evidenced by the annual performance evaluation.Keep abreast of departmental and organizational activities.Demonstrate flexibility in response to unexpected change in workload or situations.Serve on committees and / or participate in changes of policy and procedures that affect the revenue cycle.Assist in the orientation of new personnel as directed.Support the mission and goals of the company as observed.Address all emails within 24 hours.Perform other duties as required.Demonstrate Safe and Cost‑Effective Practice
Consistently adhere to OSHA bloodborne pathogen guidelines; apply universal precautions as observed.Use proper body mechanics consistently.Accurately complete incident reports within the shift of occurrence and immediately communicate critical incidents to the appropriate person per the organizational chart.Allocate resources to reduce waste and minimize costs as observed.Complete assigned duties within stated shifts in a timely manner as observed and documented.Behavioral Expectations
Strive for Excellence
Set challenging goals.Produce quality work in a timely fashion.Maintain current knowledge and skill.Participate in quality and process improvement efforts.Keep the work area clean, safe and secure.Act Flexibly
Adapt to change.See the value of different opinions and new ideas.Change plans and objectives given new direction or priorities.Handle stressful situations effectively.Meet Customer Needs
Meet internal and external customers’ needs.Find new ways of satisfying customers.Participate in service improvements efforts.Listen and respond to customers.Treat customers with compassion and respect.Work as a Team
Work as a team player.Pitch in to help those in need.Communicate with others appropriately.Listen and respond to others.Handle conflict situations effectively.Foster trust and respect within the team.Participate in committees and taskli>Foster Diversity in the Workforce
Treat all associates and customers with respect, integrity and dignity regardless of background, race, age, gender, gender identity, sexual orientation, religion or disability.Treat all associates and customers fairly.Be Self‑Directed
Take initiative and responsibility for actions.Identify own learning needs and create / implement learning plans.Perform duties according to policies and procedures.Demonstrate ethical behaviors.Maintain confidentiality of information.Maintain licenses and certifications as appropriate.Fulfill operating unit / clinical competencies.Use equipment / resources responsibly.Approval Required for :
Change in procedure.Difficult patient situations.Any situation you are unsure of.Job Scope and Work Environment
Confidential information.Extended time sitting at a desk, utilizing a keyboard and multiple monitors.High stress environment due to turnaround requirements.Daily hours subject to change on a daily basis due to schedule.Patient Privacy (HIPAA)
Protection of patient privacy.Patient records and EMR are for treatment use only.Job Requirements
Knowledge of Electronic Medical Record.Good typing skills.Good internet navigation skills.Knowledge of instrumentation used in office (fax, credit card, copy).Knowledge of multi‑line phone system.Knowledge of medical terminology with strong focus on the vascular, spine and skeletal system.Knowledge of federal, state, and payer‑specific regulations and policies pertaining to documentation, coding, and billing, with demonstrated ability to interpret such guidelines.Advanced knowledge and skill in CPT, ICD‑10‑CM and HCPCS code assignment.Strong communication and organizational skills.Education and Experience
Previous hospital / ambulatory surgery center, or physician billing experience preferred.Minimum of 2 years experience working with health insurance verification, insurance authorizations, or specialist referrals.Special Job Characteristics
Fast‑paced work environment with established time constraints.Must be able to work overtime when required.Must be able to multitask while maintaining accuracy.Must work well with others.Other Requirements
Knowledge of common safety hazards and precautions to establish a safe work environment.Must be able to act calmly and effectively in busy, stressful or emergency situations.Ability to communicate effectively in person, by phone and in writing.Requires adherence to all policies and procedures, including standards for safety, attendance, punctuality and personal appearance.This position must be willing to do any additional tasks as assigned by management.Physical Requirements
Hearing : Adequate to perform job duties in person and over the telephone.
Speaking : Must be able to communicate clearly to patients & staff in person and over the telephone.
Vision : Requires eyesight correctable to 20 / 20 to operate equipment and read information from printed sources and computer screens.
Other : Requires frequent lifting and carrying items weighing up to 50 pounds unassisted, including assisting patients when required. Adequate physical ability to be present where needed.
Requires frequent bending, reaching, repetitive hand movements, standing, walking, squatting and sitting, with some heavy lifting, pushing and pulling exerted regularly throughout a regular work shift. Requires exposure to communicable diseases, bodily fluids, medicinal preparations and other conditions common to a clinic environment.
The above is intended to describe the general content and requirements for the performance of this position. It is not to be construed as an exhaustive statement of duties, responsibilities, or requirements.
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