Pre-Certification Coordinator

JOB TITLE: Pre-Certification Coordinator
EMPLOYER: Progressive Spine & Orthopedics
REPORTS TO: Logistics Manager
PAY RANGE: OPM Pay Grade 5 (Hourly)
FLSA STATUS: Non-Exempt

SUMMARY: The Pre-Certification Coordinator is responsible for obtaining prior authorizations and pre- certifications for all medical procedural orders, ensuring timely approval to avoid delays in patient care. The Pre-Certification Coordinator works closely with healthcare providers, insurance companies, commercial payers, workers compensation insurance, motor vehicle insurance, and patients to gather necessary information and documentation for the pre-certification process.

DUTIES AND RESPONSIBILITIES:

- Review chart documentation to ensure patients meet medical policy guidelines.
- Prioritize incoming authorization requests according to urgency.
- Obtain authorization via payer website or by phone and follow up regularly on pending cases.
- Maintain individual payer files to include up to date requirements needed to successfully obtainauthorizations.
- Initiate appeals for denied authorizations.
- Respond to clinic questions regarding payer medical policy guidelines.
- Confirm accuracy of CPT and ICD-10 diagnoses in the procedure order.
- Contact patients to discuss authorization status.
- Maintain accurate records of pre-certification requests and approvals.
- Collaborate with the billing department to ensure accurate billing based on pre-certificationapprovals.
- Demonstrates a high level of professionalism in dealing with confidential and sensitive issues.
- Follow up with patient to confirm authorization and booked appointment.
- Performs other related duties as assigned by management.

QUALIFICATIONS:
- High School diploma or equivalent.
- Previous experience in pre-certification or medical billing preferred.
- Knowledge of medical terminology, insurance billing processes, and pre-certification requirements.
- Strong communication skills, both written and verbal.
- Excellent organizational skills and attention to detail.
- Ability to work independently and as part of a team.
- Proficiency in computer applications, including MS Office.
- Versatility, flexibility, and a willingness to work within constantly changing priorities with enthusiasm.
- Bilingual skills a plus.
- Professional appearance and demeanor

GENERAL EXPECTATIONS:
- Behave in a professional manner and consistently demonstrate and promote the values of respect, honesty, and dignity for the patient, families, and all members of team.
- Committed to the constant pursuit of excellence and teamwork in improving the care of the patients.
- Be punctual with scheduled work and use time appropriately.
- Perform duties in a conscientious, cooperative manner.
- Perform required amount of work in a timely fashion with a minimum of errors.
- Maintain confidentiality and protect the practice by abiding by laws and principles related to confidentiality; keeps information concerning practice operations, patients, and employees confidential.

PHYSICAL DEMANDS AND WORK ENVIRONMENT:

DOL/FLSA CLASSIFICATION ASSESSMENT:
This position is classified as Non-Exempt under the Fair Labor Standards Act (FLSA). The Pre-Certification Coordinator performs operational and administrative coordination duties and does not exercise independent authority over significant business policy decisions nor maintain primary supervisory authority over other employees. The role does not meet the federal criteria for exemption under the executive, administrative, or professional exemptions. Overtime compensation will be paid in accordance with applicable federal and state wage and hour laws.

The above is intended to describe the general content of and requirements for the performance of this job. It is not to be construed as an exhaustive statement of duties, responsibilities, or physical requirements. Nothing in this job description restricts managements right to assign or reassign duties and responsibilities to this job at any time. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

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