Precertification Specialist - The Longstreet Clinic - Pediatrics
On-siteGainesville, Georgia, United States
Job Summary
Ensure timely pre-authorization for inpatient and outpatient accounts by verifying eligibility, interpreting clinical justifications, and mediating physician-to-physician reviews. Obtain complete insurance information, collaborate with case management and referring offices to resolve authorization delays, and document all verification activities accurately. Act as the primary liaison between clinical staff, patients, and payers to address denials and support the appeals department in overturning rejected claims. Monitor authorization trends to identify process improvement opportunities while meeting department goals for productivity, accuracy, and customer satisfaction under the supervision of the Utilization Review Manager.
Required Qualifications
- High School Diploma or GED
- Ability to work independently
- Emotionally mature
- Ability to function effectively under stress
- Excellent problem solving and analytical skills
- Excellent written and oral communication skills
- Ability to prioritize, organize, and coordinate daily work load
- Working knowledge of Protected Health Information
- Ability to manage change
- Extensive knowledge of medical terminology
- Must possess detailed understanding and knowledge of insurance guideline and protocols
- Knowledge of the components of full verification
- Knowledge of payer information / requirements
- Ability to make informed decisions as to when a pre-authorization is needed
- Reading
- Writing
- Reasoning
- Talking
- Keyboarding
- Weight Lifted: Up to 20 lbs
- Weight Carried: Up to 20 lbs
- Vision: Moderate, Constantly 66-100% of time
- Kneeling/Stooping/Bending: Occasionally 0-30% of time
- Standing/Walking: Occasionally 0-30% of time
- Pushing/Pulling: Occasionally 0-30% of time
- Intensity of Work: Occasionally 0-30%
Desired Qualifications
- AAPC, AHIMA or CPC certification
- 3–5 years of relevant experience in insurance authorization, precertification, medical billing, revenue cycle, patient access, or related healthcare operations
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