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, customers and vendors via fax, phone and portal
- 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 customer coverage and benefits
- Review authorization requests and make determinations on correct authorization process (i.e. auto approve, refer to Utilization Management Nurse)
- Maintain benchmark standards for TAT (Turn-Around-Time) as established by the organization.
- 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 in accordance with Time Away From Work policy
- Ability to work evening, weekend and holiday shifts to support the UM Department
- Other duties as requested
Qualifications:
- High School Diploma and preferred 1-2 years’ experience in a managed care environment
- Proficient in medical terminology, CPT, HCPCS and ICD-10 coding
- Effective oral and written communication skills
- Strong customer orientation
- Substantial knowledge of Microsoft Office including Outlook, PowerPoint, Excel and Word
- Excellent typing skills
Knowledge, Skills, Abilities Required:
- Excellent interpersonal and communications skills with nursing staff, physicians, nurse practitioners and other health workers involved in the care of a customer
- Ability to meet deadlines and manage multiple priorities, and effectively adapt and respond to complex, fast-paced, rapidly growing, and results-oriented environment
- Proficient knowledge of departmental policies and procedures
- Knowledge of Medicare Regulatory Requirements
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