Pre-Certification Specialist (Full-Time)

OrthoNebraska creates the inspired healthcare experience all people deserve by giving people a direct path to personalized care and life-enhancing outcomes. With a focus on safety and people, we set the bar high in providing high-quality care with an unmatched experience. Our team members are critical to our success and growth and are rewarded for their dedication and hard work. IF this sounds like the type of team and environment you want to be a part of apply today!

Position Summary: The Pre-Certification Specialist, is responsible for verifying patient insurance coverage and benefits, obtaining prior authorizations for services from insurance companies by reviewing medical records and submitting required documentation to ensure timely and appropriate patient care, acting as a liaison between healthcare providers and insurance payers to facilitate smooth treatment delivery.

Position details

Position Requirements

Education: High School Diploma or General Educational Development (GED) required.

Licensure: N/A

Certification: N/A

Experience: 2+ years' experience in a healthcare environment required.

Required Knowledge/Skills/Abilities

• Knowledge of insurance terms, Medical Terminology, CPT and ICD-10 codes preferred.
• Excellent verbal and written communication skills required.
• Excellent telephone etiquette.
• Detailed oriented.

Essential Job Functions

• Primary job role includes verifying insurance eligibility, benefits, and pre-certification/authorization requirements of surgeries, and/or other clinical and ancillary services
• Verifies insurance eligibility and benefits using carrier specific tools.
• Receives, manages, and processes inbound provider orders for services in a timely manner. Including monitoring incoming additions, revisions, and cancellation of procedures
• Initiates expedited reviews with payers when necessary to ensure authorization is in place prior to, or at the time of service
• Monitoring cases pending or not yet started which can be a minimum of 1 month out from scheduled date of services. Must be mindful of payer specific processing time frames and clinical documentation that is needed for submission of authorization request
• Document in patients' chart, full detail of interactions with payers regarding status and authorizations
• Remains apprised on payer requirements surrounding authorization guidelines for services provided
• Meets productivity and quality standards and following all documentation guidelines communicated by leadership
• Maintain confidentiality through HIPPA and demonstrates respect for patient rights
• Engage in performance improvement activities
• Comply with safety policies and procedures, regulatory requirements
• Other duties may be assigned at times as determined by a supervisor to meet the needs of the organization

Physical requirements: This position is classified as Sedentary Work in the Dictionary of Occupational Titles, requiring the exertion of up to 10 pounds of force occasionally) up to (33% of the time) and/or a negligible amount of force frequently (33%-66% of the time) to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time.