Pre-Certification Specialist
Core
Verify patient insurance eligibility and obtain prior authorizations/pre-certifications for procedures and services to ensure coverage and support revenue cycle performance.
Role type
Pre-Certification Specialist (Healthcare Revenue Cycle)
Builds
Prior authorization approvals and denial management for surgical procedures, diagnostic tests, and specialty services
Domain
Healthcare / Insurance Administration
Required skills
Insurance verification, Prior authorization, Medical billing, Revenue cycle management, ICD-10 coding, CPT coding, Medical terminology, Anatomy knowledge, EMR systems, Practice management systems
Preferred skills
Experience in physician practice, outpatient clinic, hospital, or specialty healthcare setting, Surgical pre-certification experience
Responsibilities
Verify patient insurance eligibility, benefits, and coverage; Obtain prior authorizations and pre-certifications for procedures and services; Review physician orders and clinical records to identify authorization requirements; Send authorization requests and medical records to insurance carriers; Track authorization approvals, denials, and expirations; Prepare appeals and reconsideration requests for denied services; Maintain accurate records of authorization activities in EMR and practice management systems.
Seniority
Mid-level, hands-on specialist