Precertification Specialist

About the role

Join RCCA and make a meaningful impact on the patient journey. As a fully remote Precertification Specialist, you will be responsible for obtaining and managing prior authorizations to ensure patients receive timely access to the care and treatment they need. This role requires strong attention to detail, problem-solving skills, and a commitment to delivering exceptional service while navigating complex insurance requirements.

Responsibilities

• Under general supervision, ensure prior authorizations are obtained in a timely manner and remain current to facilitate uninterrupted patient care.
• Review and confirm patient insurance eligibility, benefits, and coverage for specific services, ensuring alignment with payer requirements.
• Follow standard operating procedures and established guidelines to complete prior authorization tasks in a compliant and accurate manner.
• Proactively follow up with insurance carriers on pending or denied authorizations, submitting appeals when necessary.
• Resolve issues or discrepancies related to prior authorization requests.
• Support and adhere to the US Oncology Compliance Program, including the Code of Ethics and Business Standards and US Oncology's Shared Values.
• Monitor assigned worklists and emails to provide front-end review for authorization and answer questions related to authorizations.
• Contact patients to discuss out-of-pocket costs, offer assistance options (if available), and coordinate outreach for patient plan initiation (if applicable).
• Review weekly denial report and resolve issues, including submitting retro authorization requests or front-end appeals.
• Adhere to workflow and escalate issues to Supervisor promptly.
• Adhere to confidentiality and all state, federal, and HIPAA laws and guidelines regarding patient records.
• Perform other duties as requested or assigned.

Qualifications

• High School diploma or equivalent required.
• Minimum two (2) years of experience in a patient access or financial clearance role; oncology experience preferred.
• Demonstrate advanced knowledge of medical terminology.
• Ability to navigate different systems seamlessly and multitask efficiently.
• Must successfully complete required e-learning courses within 90 days of occupying position.

Competencies

Technical and Functional Expertise

• Maintain current knowledge of healthcare reimbursement, insurance authorization requirements, industry standards, and applicable regulations.
• Apply technical knowledge and established processes to ensure accurate and timely completion of prior authorization activities.
• Effectively utilize available tools, systems, and resources to support operational goals and patient needs.

Adaptability and Resilience

• Demonstrate flexibility and adaptability in a fast-paced healthcare environment.
• Effectively manage multiple priorities while maintaining accuracy and attention to detail.
• Respond positively to changing business needs, shifting priorities, ambiguity, and organizational change.
• Maintain composure and productivity when faced with challenges, setbacks, or competing demands.

Customer Service Excellence

• Build and maintain positive working relationships with patients, physicians, coworkers, supervisors, insurance carriers, and other external partners.
• Communicate professionally, respectfully, and effectively to support positive patient experiences and successful team collaboration.
• Demonstrate a service-oriented approach that promotes patient satisfaction and operational excellence.

Judgment and Decision-Making

• Exercise sound judgment when evaluating information, resolving issues, and determining appropriate courses of action.
• Make timely, accurate, and cost-effective decisions while ensuring compliance with organizational policies and payer requirements.
• Demonstrate the ability to make informed decisions in situations involving uncertainty or limited information.

Accountability and Work Commitment

• Take ownership of responsibilities and follow through on commitments.
• Establish and maintain high standards of performance and professionalism.
• Demonstrate initiative and a strong commitment to achieving individual and departmental goals.
• Work efficiently and effectively to meet productivity, quality, and service expectations.

Quality and Continuous Improvement

• Consistently deliver high-quality work and services with a focus on accuracy and compliance.
• Support and promote quality standards across all aspects of job performance.
• Identify opportunities to improve workflows, enhance operational effectiveness, and increase efficiencies.
• Contribute to continuous improvement efforts that support exceptional patient care and organizational success.

Physical demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations will be offered to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit and use hands to manipulate a computer keyboard and mouse. The employee is occasionally required to stand, walk, and reach with hands and arms. The employee must occasionally lift and/or move up to 30 pounds. Requires vision and hearing corrected to normal ranges.

Work environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations will be offered to enable individuals with disabilities to perform the essential functions. Work is performed in an office environment. Involves frequent contact with staff. While performing the duties of this job, the employee is regularly exposed to direct contact with patients with potential for exposure to blood, toxic substances, ionizing radiation and other conditions common to a clinic environment.