Pre-certification Coordinator

Medical Pre-certification Specialist (Ophthalmology)

The Medical Precertification Specialist is a crucial part of our ophthalmology practice revenue cycle management team. This role is responsible for obtaining timely prior authorizations, precertification’s, and referrals for all ophthalmic procedures and surgeries.

By ensuring coverage determination and establishing patient financial responsibility, this position facilitates a seamless patient experience and helps prevent claim denials.

Key Responsibilities

· Prior Authorization: Prepare, submit and follow up on all prior authorization requests with insurance payers for scheduled and unplanned service, ensuring adherence to carrier-specific time limits and medical policies.

· Insurance Verification & Financial Counseling: Verify insurance eligibility, benefits and coverage for all medical plans. Calculate and discuss estimated financial responsibility, such as deductibles and coinsurance and collect payments prior to the date of service.

· Documentation & Coding: Extract pertinent clinical information from electronic health records to provide clinical justification to payers. Ensure all documentation supports medical necessity and utilize appropriate CPT and ICD-10 codes.

· Communication & Collaboration: Act as the primary liaison between insurance companies, physicians and patients. Notify all relevant parties of authorization statuses and coordinate any necessary follow-up or appeal processes.

· Compliance & Record Keeping: Maintain accurate and detailed records of all insurance interactions, authorizations, and approvals in the HER and Practice Management system in compliance with HIPAA regulations.

Qualifications

· Prior experience in a medical office setting, specifically with insurance knowledge related to prior authorizations (2 Years +)

· Strong knowledge of medical plans, medical terminology and CPT /ICD-10 coding guidelines

· Proficiency in using EHR systems and online insurance payer portals

· Exceptional attention to detail, organized, and ability to multi-task

Pay is negotiable with experience!

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee discount
• Health insurance
• Health savings account
• Life insurance
• Paid time off

Work Location: In person