PreCert Specialist - Full-Time - Germantown, TN

West Cancer Center•Germantown, TN

About The Position

The PreCert Specialist is responsible for ensuring patients have the required precertification for procedures, drugs, and radiology services, and for entering patient information into the system. The role serves as a resource for patients, providers, and staff by navigating insurance requirements, obtaining authorizations, and maintaining accurate documentation.

Requirements

High school diploma or equivalent.
At least three years of experience in healthcare insurance or a medical clinic, emphasizing precertification or predetermination.
Experience reviewing medical necessity, payer policies, and medical coverage criteria.
Experience in a high-volume medical clinic or healthcare environment.
Strong knowledge of managed care, medical terminology, precertification processes, and insurance claims processing.
Familiarity with ICD-9, ICD-10, CPT, and HCPCS coding systems for chemotherapy precertification requests.
Proficiency with Microsoft Office applications and multiple healthcare systems and websites.
Excellent navigation skills using intranet and internet resources.
Strong organizational skills and ability to handle high patient volumes.
Excellent problem-solving skills and strong attention to detail.
Strong written and verbal communication abilities.
Knowledge of clinical coverage guidelines and medical policies.

Nice To Haves

Experience with chemotherapy and radiology precertifications.

Responsibilities

Verify demographic and insurance information, including co-pays, deductibles, stop losses, guarantors, subscribers, and medical policy requirements.
Update demographic and insurance records accurately and promptly.
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 their status, and coordinate with patient assistance programs when applicable.
Support appeals and peer-to-peer requests related to precertification denials.
Assist medical teams with cases returned from the office site team to resolve issues.
Maintain compliance with policies, procedures, and performance standards.
Perform other duties as assigned.