Pre-Certification Specialist

Job Summary

Processing precertification requests in a fully remote capacity, the Pre-Certification Specialist will manage high-volume calls from members and healthcare professionals, verify eligibility, and ensure compliance with state and federal regulations.

Key responsibilities

• Answer incoming calls regarding precertification requests and verify member eligibility using multiple systems
• Process precertification requests and obtain necessary clinical information while adhering to departmental guidelines
• Identify requests for medical necessity reviews and ensure compliance with corporate quality standards

Required qualifications

• High school diploma required; associate degree in a related field preferred
• A minimum of three years of customer service experience in the health insurance or health services industry
• Knowledge of medical terminology and familiarity with ICD9/ICD10 and CPT codes
• Experience with computerized databases, including Word, Excel, and Mainframe
• Knowledge of INSINQ is a plus