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 s 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 medication s -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.

Other functions and Responsibilities

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

• Patient & Customer Focus
• Ethical Conduct
• Flexibility
• Initiative
• Personal Effectiveness/Credibility
• 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