Pre-Certification Specialist (remote) - 240001

　　DESCRIPTION/RESPONSIBILITIES:Under the direction of a manager and licensed health professionals, the Pre-Cert Specialist processes precertification requests in accordance with established corporate guidelines and in compliance with all state and federal regulations.  

　　Major Activities: * Answers incoming telephone calls in a high-volume Call Center environment from members and health care professionals regarding requests for precertification of health services. * Verifies member eligibility by accessing multiple eligibility systems * Verifies participation status of professional and facility providers, by product and state utilizing multiple database systems including the National Provider Identification(NPI) Registry * Processes precertification requests from members and providers received telephonically,  via fax or NaviNet per department guidelines   * Obtains all clinical information including procedure and diagnosis codes * Enters all pertinent data in the appropriate computer system * Approves selected services per departmental guidelines * Identifies precertification requests that warrant a medical necessity review   * Identifies potentially cosmetic and investigative/experimental procedures    * Adheres to the departmental standards for staff time, after call work, attendance and non-queue production * Adheres to the corporate quality customer-focused professionalism and accuracy standards * Responds to voicemails and emails within one business day, as necessary * Performs additional duties as assigned

　　Education and Experience Required: * High school diploma required, associate degree in a related field preferred.   * A minimum of three years of customer service experience in the health insurance industry or health services industry strongly recommended including knowledge of medical terminology, a general understanding of managed care delivery systems and a familiarity with ICD9/ICD10 and CPT codes. * Excellent organizational, interpersonal, verbal and written communication skills, necessary * Detailed oriented with an ability to accept and respond to changes.  * Experience accessing, navigating, and data entering into computerized databases required.  Specifically, Word, Excel, and Mainframe  * Knowledge of INSINQ is a plus Equal Opportunity Employer-minorities/females/veterans/individuals with disabilities/sexual orientation/gender identity