Pre-certification Medical Specialist

Job Description

Job Description

Work Location

This is a full-time remote opportunity (M-F 8hour shift between 7:30am - 5:30pm). Candidates must reside in one of the following states: Arizona, Arkansas, Florida, Iowa, Illinois, Indiana, Michigan, Missouri, North Carolina, Nevada, Ohio, Oregon, Pennsylvania, Tennessee, or Texas.

Position Overview

As a Pre-Certification Specialist , you will be responsible for coordinating and maintaining the flow of information throughout the managed care referral and authorization process. This role works closely with physicians, clinical staff, insurance carriers, and other healthcare providers to help ensure timely and accurate authorization of patient services.

Experience or familiarity with orthopedics, pain management and spine-related procedures and terminology required.

Essential Duties & Responsibilities

• Manage inpatient and outpatient referral and pre-authorization processes.
• Verify insurance coverage, in-network eligibility, benefits, and authorization requirements.
• Contact referring physicians and insurance carriers to obtain required authorizations for treatment.
• Communicate with hospitals and other healthcare facilities to obtain and document pre-certification numbers.
• Consult with physicians, nurses, staff, and healthcare providers regarding referral and pre-certification requirements.
• Maintain accurate and timely documentation of referrals, authorizations, and related insurance information.
• Field inquiries regarding prescription benefits and assist with prescription verification, as applicable.
• Maintain strict confidentiality of medical records, patient information, and other sensitive data in accordance with applicable requirements.
• Participate in professional development opportunities to remain current on healthcare practices, payer requirements, and industry trends.
• Actively contribute to the company’s efforts to develop innovative data and analytics solutions for the modern orthopedic business office.
• Perform other duties as assigned.

Required Skills & Qualifications

• High school diploma or equivalent required; college coursework or relevant certification preferred.
• Excellent verbal and written communication skills, particularly over the phone, with the ability to establish and maintain positive working relationships with patients, physicians, colleagues, insurance representatives, and other stakeholders.
• Ability to efficiently gather, organize, review, and understand insurance, authorization, and patient account information.
• Proficient computer skills with the ability to navigate multiple software systems in an office environment; typing speed of approximately 50 WPM preferred.
• Knowledge of, or demonstrated ability to learn, insurance policies and procedures, payer requirements, medical terminology, and clinical workflows.
• Strong organizational and analytical skills with excellent attention to detail.
• Ability to learn quickly, adapt to changing requirements, and contribute ideas that improve team processes and solutions.
• Ability to work independently and effectively in a remote environment.
• Commitment to our values of resilience, altruism, communication, achievement, and determination.

Preferred Qualifications

• Two or more years of experience in pre-certification, prior authorization, insurance verification, or managed care.
• Previous experience working with orthopedic services is preferred.
• Familiarity with spine procedures, spine-related terminology, and associated authorization requirements is a strong plus.
• Experience communicating with insurance carriers and navigating payer portals to obtain authorizations is preferred.