Pre-Certification/Eligibility Specialist

Duties And Essential Job Functions

• 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.
• 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.

Qualifications

• 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.