Precertification Specialist

Precertification Specialist

Our award-winning medical practice client in Philadelphia is looking for a Precertification Specialist to join their team. The ideal candidate will have at least 1 year of experience with precertification. Candidates must have a good work history and are extremely detail oriented. The hours are 7am-5pm Mondays-Thursdays. Parking pass is also included. This is a Direct Hire position with hourly rate up to $26/hour with excellent benefits.

The Precertification Specialist is responsible for managing and processing prior authorization requests for biologic medications, ensuring timely and accurate approvals in compliance with payer guidelines and clinical protocols. This role requires a strong understanding of biologic therapies, insurance requirements, and healthcare workflows. The specialist works closely with Billing Director, providers, patients, insurance companies, and pharmacy teams to facilitate access to high-cost biologic treatments. Attention to detail, excellent communication skills, and the ability to navigate complex payer systems are essential.

Key Responsibilities:

• Submit and track prior authorization requests for biologic medications.
• Verify insurance benefits and eligibility for specialty therapies.
• Collaborate with providers to obtain necessary clinical documentation.
• Communicate with payers to resolve issues and expedite approvals.
• Educate patients on authorization status and next steps.
• Maintain accurate records in payer portals.
• Stay updated on payer policies and biologic drug changes.
• Enroll patients in co-pay assistance programs.
• Enter Biologic Charges.
• Run Monthly Reports
• Follow-up on denied biologic claims.
• Non-biologic billing tasks as needed.

Key Performance Metrics:

• Authorization Turnaround Time: Average time from submission to approval.
• Approval Rate: Percentage of biologic precertifications approved on first submission.
• Denial Resolution Rate: Success rate of overturned denials through appeals.
• Documentation Accuracy: Percentage of submissions with complete and correct documentation.
• Patient Communication Timeliness: Time taken to notify patients of authorization status.
• Compliance Rate: Adherence to payer-specific guidelines and internal protocols.
• Volume Management: Number of precertification cases handled per week/month.

Qualifications:

• Experience in precertification or prior authorization
• Knowledge of commercial insurance plans.
• Familiarity with specialty pharmacy workflows and biologic drug therapies.
• Strong organizational and communication skills.
• Proficiency in payer portals.
• Ability to work independently and collaboratively.