Precertification Specialist

United States

Full Time

Experienced

Precertification Specialist
Location: Tupelo
FLSA Status: Non-Exempt
Job Type: Full-Time

Position Summary:
Specialty Orthopedic Group is seeking a dedicated Precertification Specialist to join our team. This role is responsible for reviewing chart documentation, obtaining authorizations, and ensuring compliance with medical policy guidelines. The Precertification Specialist plays a critical role in supporting clinic operations, ensuring patients receive timely authorizations, and maintaining accurate records across multiple payer systems.

Key Responsibilities:

Review chart documentation to ensure patients meet medical policy guidelines.
Prioritize incoming authorization requests according to urgency.
Obtain authorizations via payer websites or by phone, and follow up regularly on pending cases.
Maintain individual payer files with up-to-date requirements for successful authorizations.
Initiate appeals for denied authorizations.
Respond to clinic questions regarding payer medical policy guidelines.
Confirm accuracy of CPT and ICD-10 diagnoses in procedure orders.
Contact patients to discuss authorization status as needed.
Perform other duties as assigned.

Systems and Sites:
ModMed, MESA, Magnolia/Ambetter, RadMD, UHC, Availity, Carelon, Telligen, Evicore, Cohere, OptumVA, Humana Military, My Visco, Flex Forward, Zimmer, BV360, Turning Point, Kepro, NIA, BCBS, Cigna.

Qualifications:

High School Diploma or GED required.
Experience with patient registration and verification of patient information.
Knowledge of patient insurance eligibility checks and navigating multiple payer sites.
Strong organizational skills and attention to detail.
Excellent customer service and communication skills.
Ability to handle ABN forms and maintain proper documentation in patient charts.
Experience with case history entry, chart auditing, and quality control preferred.

Preferred Skills:

Proactive problem-solving and ability to manage multiple priorities.
Familiarity with medical policy guidelines, CPT/ICD-10 coding, and insurance authorization processes.
Strong computer literacy and ability to navigate multiple systems efficiently.

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How many years of experience do you have working in a medical office, clinic, or healthcare setting?*

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Precertification Specialist

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