Insurance Authorization Specialist

Job Description

Job Description

Description:

Pre-Certification Specialist 

The Role: Full Time | Non-Exempt / Hourly | Administrative, Business Office

At Nebraska Spine and Pain Center, we are a multi-specialty medical practice built around one goal: getting patients the care they need without the runaround. Our Business Office is the engine behind that promise, and the people in it work closely with physicians, advanced practice providers, and clinic leadership every day. If you are looking for a role where you work actually makes a positive impact on patients, Nebraska Spine and Pain Center is your place! 

Position Overview: 

Join our Business Office and be the person who gets patients from "ordered" to "approved." This role handles pre-certification and insurance authorization for outpatient and surgical procedures. You'll work directly with payers to obtain and track coverage determinations, all in compliance with HIPAA and current payer and coding standards. 

Essential Job Functions:

• Performs pre-certification of outpatient procedures, including MRI, CT, injection, and in-house procedures, based on the ordering provider’s clinical order and current payer medical-policy criteria.
• Performs pre-certification of surgical procedures, submitting clinical documentation provided by the ordering physician or advanced practice provider.
• Follows up on pending pre-certifications with insurance carriers within established turnaround-time standards.
• Maintains working knowledge of CPT and ICD-10-CM coding conventions sufficient to support accurate, compliant pre-certification submissions; escalates coding questions requiring clinical judgment to the appropriate clinical or coding staff.
• Answers patient phone calls and provides status updates on pre-certification requests, disclosing only the minimum necessary protected health information consistent with HIPAA privacy standards.
• Documents all payer communications, determinations, and pre-certification status accurately and timely in the practice management system/EHR.
• Does not render independent medical necessity determinations; medical necessity and clinical appropriateness decisions remain with the ordering provider and, where applicable, the payer’s clinical reviewer.

Additional Responsibilities:  

• Assist business office staff with outpatient scheduling for imaging, injections and surgical 
• Provide float or cross-coverage support to other departments as needed.
• Other duties may be assigned at times as determined by a supervisor to meet the needs of the organization
• Duties, responsibilities, and activities may change without prior notice. 

Requirements:

Physical:  

• Prolonged periods of sitting at a desk and working on a computer
• Prolonged periods of phone-based communication
• Ability to lift up to 10 pounds occasionally 
• Ability to manage multiple competing tasks and deadlines
• High attention to detail and accuracy

Required Knowledge/Skills/Abilities:

• Knowledge of insurance terms, medical terminology, CPT and ICD-10 codes preferred
• Excellent verbal and written communication skills required 
• Excellent telephone etiquette 
• Detail oriented 
• High school diploma or equivalent; prior experience in medical insurance authorization, medical billing, or a related healthcare business-office function preferred