Job Information
Independence Blue Cross, LLC Pre-Certification Specialist - 240665 in Philadelphia, Pennsylvania
Pre-Certification Specialist - 240665
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 * Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.
This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence's physical office locations to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania.
Equal Opportunity Employer-minorities/females/veterans/individuals with disabilities/sexual orientation/gender identity