The Pre-Certification Specialist is responsible for supporting the Precertification Nurse, Medical Director and Director of Health Services by collecting, interpreting and evaluating medical information received for authorization. The Pre-cert Specialist will communicate with internal and external providers regarding authorization status.
Essential Duties and Responsibilities:
Receive request for authorization from hospitals, providers, members and vendors; Meet service level goals (e.g., Grade of Service, Average Handle Time, Average Speed to Answer, abandonment rate).
Determine authorization requirements based on company policy, member benefit grid and provider status.
Review authorization requests and make determinations on correct authorization process (i.e. auto approve, refer to Precert Nurse or Medical Director).
Maintain benchmark standards for TAT (Turn Around Time) as established by the organization.
Provide determinations on authorizations request to members and/or providers based on benchmark standards for authorization decisions. Process extensions of authorizations as appropriate.
Processes denials including correspondence sent to families, members, facilities and applicable contracted providers
Notifies responsible parties prior to initiation of denial letter and ensures that member and responsible party understand details of the letter and the appeals processes to follow
Completes review of non authorized medical claims
Proficient knowledge of departmental policies and procedures; knowledge of Medicare, HIPPA and NCQA ;
Professional demeanor and the ability to work effectively within a team or independently;
Flexible with the ability to shift priorities when required;
Maintains regular and acceptable attendance at such level as is determined at the employer’s sole discretion
Other duties as requested
High School Diploma and 3-4 years experience in a managed care environment.
Must be proficient in medical terminology, CPT and ICD-9/ICD-10 coding
Knowledge, Skills, Abilities Required:
Excellent interpersonal and communications skills with nursing staff, physicians, nurse practitioners and other health workers involved in the care of a member
Able to work in a dynamic, fast-paced team environment and to promote team concepts
Substantial knowledge of Microsoft Office including SharePoint, Outlook, PowerPoint, Excel and Word.
Qualified applicants will be considered for employment without regard to age, race, color, religion, national origin, sex, sexual orientation, gender identity, disability, veteran status. Need an accommodation? Email: SeeYourself@cigna.com