PreCert Specialist - Full-Time - Germantown, TN

The role

The PreCert Specialist ensures patients have required precertification for procedures, drugs, and radiology services. This person enters patient information and navigates insurance requirements to obtain authorizations.

What you will do

• Verify demographic and insurance information including co-pays, deductibles, stop losses, guarantors, subscribers, and medical policy requirements
• Update demographic and insurance records in a timely and accurate manner
• Obtain and review physician orders for medical necessity and coverage requirements
• Research insurance coverage criteria using payer policies, medical literature, and compendiums
• Generate and review computer-based appointment reports
• Communicate proactively with medical teams to ensure criteria are met for authorization
• Obtain and review authorizations to ensure appropriate payment on the backend
• Review self-pay patients, confirm status, and coordinate with patient assistance programs if applicable
• Support appeals and peer-to-peer requests for precertification denials
• Assist medical teams with cases returned from the office site team to resolve issues

Required qualifications

• High school diploma or equivalent
• Minimum three years’ experience in healthcare insurance or medical clinic, with emphasis on obtaining precerts/predeterminations
• Experience reviewing medical necessity, payer policies, and medical coverage criteria
• Experience in high-volume medical clinic or healthcare environment
• Strong knowledge of managed care, medical terminology, precert processes, and insurance claims processing
• Familiarity with coding systems (ICD-9, ICD-10, CPT, HCPCS) for chemotherapy precertification requests
• Proficiency with Microsoft Office applications and multiple healthcare systems/websites
• Excellent navigational skills using intranet and internet resources
• Strong organizational skills with ability to handle high patient volumes
• Excellent problem-solving skills and high attention to detail
• Strong written and verbal communication abilities
• Knowledge of clinical coverage guidelines and medical policies

Nice to have

• Experience with chemotherapy and radiology precertifications

Benefits

• Comprehensive benefits package

About the company

West Cancer Center is a comprehensive, patient-centered cancer care and research institution. Their multidisciplinary teams deliver integrated care tailored to the needs of each individual and their loved ones.