Pre-Certification/Eligibility Specialist

Job Summary

This position is primarily responsible for pre-certifying procedures and surgeries ordered by physicians. This position is also responsible for coordinating with patients, insurance companies, hospitals, primary care physicians and/or any other medical representatives by performing the following duties.

Duties and Essential Job Functions

• Core duties and responsibilities include the following. Other duties may be assigned.
• Processes surgery schedulers packets for benefits according to protocol.
• Contacts patient insurance carrier to verify benefit information and eligibility.
• Faxes Request for Authorizations and/or any other forms insurances request, as well as all clinical information on to insurance carrier.
• Annotates on chart patient's policy limits and/or any co-pays, etc. in E.M.R. (Electronic Medical Record). Annotate authorization number on surgery schedule
• Prepares Letter of Medical Necessity and/or paperwork as required by patient insurance to begin appeal process, as needed.
• Submits insurance verification forms to supplier of products on patients using prosthetics.
• Sets up Peer to Peer review between physician and insurance carrier if prior authorization has been denied.
• Advises physician and begin appeals process when procedure is exclusion to patient's plan.
• Obtains authorization for administration and specialized medications -authorization obtained through Medication Intake Department or through Specialty Pharmacy
• Maintains constant communication with billing department in the event of insurance error or changes to patient insurance in order to file or re-file claim.
• Performs other duties as assigned.

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Competencies

1. Patient & Customer Focus
2. Ethical Conduct
3. Flexibility
4. Initiative
5. Personal Effectiveness/Credibility
6. Stress Management/Composure

Qualifications

Required

• 6 months experience as a medical front desk with durable expertise of coding.
• 6 months related experience and/or training, or comparable blend of education and learning and experience.
• Willingness to attend continuing education courses at the request of the employer.
• Strong medical terminology
• Knowledge of insurances and respective requirements