Nemours is seeking a Pre-Certification Specialist II (Full-Time), to join our team in Orlando, Florida.

The Pre-Certification Specialist II is responsible for obtaining referrals and/or precertification's for assigned specialties withing seventeen to twenty (17-20) days prior to the patient's scheduled service. The specialist will also ensure that the insurance has been verified; referrals/precertification's have been obtained and linked to the correct accounts with accurate documentation in the Epic system. The Precertification Specialist will also ensure that all denied referral/precertification requests are communicated to the appropriate areas.

• Knowledge of participating insurances and authorization requirements.
• Responsible for obtaining complete and accurate insurance information, benefit verification, accurately interpreting benefit plans and investigating pertinent details.
• Ability to verify patient eligibility and precertification requirements through online resources or via telephone.
• Effectively communicate with families; when appropriate, regarding benefit details and limitations.
• Documents detailed communication with payors and clinical support in the authorization fields.
• Contacts family with any insurance issue s that may prevent obtaining a referral/precertification.
• Reviews and processes accounts in DAG work queue to ensure performance management goals are met.
• Timely management of incoming Right Fax responses.
• Provide team coverage when needed.
• Attend insurance in-service meetings when appropriate.
• Other duties as assigned.

Job Requirements

• High School Diploma required.
• Minimum one year of experience required.
• Minimum of two (2) years of medical insurance precertification experience required. Florida Medicaid knowledge preferred.
• Knowledge of CPT, ICD-10 codes, and medical terminology required.
• Insurance authorization experience preferred.
• Other duties as assigned.

Schedule:

Monday - Friday 8:30AM - 5:00PM.