Pre-Certification Specialist

OrthoNebraska is adding a Pre-Certification Specialist to our Patient Financial Services team to accommodate practice growth and regulatory compliance. Our focus is on accurately and effectively facilitating the communication between patients, our providers, and insurance companies. Teamwork is key within this department as we are dedicated to ALWAYS TRUE, in promoting trust, respect, understanding and engagement with all our team members.

The Center for Medicare & Medicaid Services (CMS) requires all healthcare workers, as well as individuals who interact with healthcare workers in a work setting, be fully vaccinated against COVID-19 as a condition of employment unless a medical or religious exemption is approved. At this time, fully vaccinated means that an individual is at least two weeks past their final dose of an authorized COVID-19 vaccine regimen. Final candidates must be fully vaccinated as of their first day of employment. As a condition of employment, newly hired team members will be required to provide proof of their COVID-19 vaccination or apply for a medical or religious exemption.

Department/Position Details/Duties:

• 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

Position Requirements:

Education:

• High School diploma or equivalent
• Knowledge of insurance terms, Medical Terminology, CPT and ICD-10 codes preferred

Experience:

• Prior experience in a healthcare environment preferred
• Excellent verbal and written communication skills required
• Excellent telephone etiquette
• Detailed oriented

Physical:

• 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.