Responsible for completing precertification, prior authorization, and notification tasks for third-party and government payers for scheduled outpatient procedures and diagnostic testing.

The role communicates with insurance companies, clinic staff, outside physician offices, facilities, and patients to ensure authorizations are obtained in a timely manner.

Key duties include:

Prioritizing and processing incoming authorization requests and orders
Reviewing clinical documentation to identify information supporting medical necessity
Obtaining patient benefit and eligibility status for pending procedures
Communicating with payers and utilization management companies
Identifying payer trends and sharing feedback with the billing team supervisor and providers
Appealing denied authorizations when appropriate
Initiating peer-to-peer reviews and preparing documentation packets
Maintaining knowledge of payer medical policies and guidelines
Managing work queues, emails, and phone messages promptly
Supporting revenue cycle activities, onboarding, committee work, and process improvement efforts

Qualifications

Knowledge of electronic medical records

Strong typing and internet navigation skills

Familiarity with office equipment and multi-line phone systems

Knowledge of medical terminology, especially vascular, spine, and skeletal systems

Knowledge of federal, state, and payer-specific regulations and policies related to documentation, coding, and billing

Advanced knowledge of CPT, ICD-10-CM, and HCPCS code assignment

Strong communication and organizational skills

Previous hospital, ambulatory surgery center, or physician billing experience preferred

Minimum of 2 years of experience in health insurance verification, insurance authorizations, or specialist referrals

Precertification Specialist

Qualifications

Additional expectations