Remote Pre-Certification/Authorization Specialist

About this Position:

• Contacts insurance companies and other third-party payers to determine Pre-Authorization requirements for basic and moderately complex outpatient hospital services.
• Calls insurance companies or uses online tools to obtain pre-authorization and/or referral prior to service date. Follows-up timely and thoroughly.
• Ensures all pre-authorization issues are communicated in a timely manner.
• Liaisons with physician’s staff to obtain additional insurance and/or clinical information.
• Confirms eligibility, coverage, and benefits with insurance companies. Determines financial responsibility for service.
• Reviews patients' charts for clinical justifying medical necessity for the service.
• Follows up properly on all denials and peer-to-peer requests.
• Researches and assists with denied pre-authorization or pre-determinations.
• Documents appropriately regarding all actions, authorization, referral details, and referral modifications for specialty care and testing for patients with insurance plans requiring formal referral documentation.

Qualifications:

• Formidable knowledge of copay's, deductibles, co-insurance for In-network & out-of-network medical benefits.
• Able to prioritize, work accurately, work well independently, and able to maintain focus under pressure.
• Working knowledge of medical terminology, insurance packages/plans, and proficiency with EMR.
• Strong knowledge of government payers. Claim status follow-up is a plus.
• Clearly communicate with providers, insurance companies, staff, and patients.
• Excellent verbal and written communication skills.
• Excellent organizational skills, Multi-tasking capabilities, and detail orientated.
• Customer Services skills with heavy phone contact and client interface.
• Basic Computer/PC and Internet skills.
• Working with MS office products/ Excel and Word.
• Attention to detail and problem-solving skills.
• Must be a great team player and passionate about working.