Pre-Certification Specialist II

Job Description

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.

About Us

Nemours Children’s Health is an internationally recognized children’s health system. With more than 1.7 million patient encounters annually, we provide medical care in five states through two freestanding state-of-the-art children’s hospitals — Nemours Children’s Hospital, Delaware and Nemours Children’s Hospital, Florida. Our pediatric network includes 80 primary-urgent-and specialty care practices and more than 40 hospitalists serving 19 affiliated hospitals. We generate annual revenues of more than $1.7 billion derived from patient services, contributions from the Alfred I. DuPont Trust, as well as other income.

As one of the nation's premier pediatric health systems, we’re on a journey to discover better ways of approaching children’s health. Putting as much focus on prevention as cures and working hand in hand with the community to make every child’s world a place to thrive. It’s a journey that extends beyond our nationally recognized clinical treatment to an entire integrated spectrum of research, advocacy, education, and prevention, leading to the healthiest generations of children ever.

Equity, diversity, and inclusion guide our growth and strategy. We are looking for individuals who are passionate about, and committed to, leading efforts to provide culturally relevant care, reducing health disparities, and helping build a diverse and inclusive environment. All of our associates are expected to ensure that these philosophies are embedded in their day-to-day work with colleagues, patients and families.

To learn more about Nemours Children’s and how we go well beyond medicine, visit us at www.nemours.org .