This job listing has expired and the position may no longer be open for hire.

Pre-Certification Specialist II (Full-Time) at Nemours

Posted in General Business 30+ days ago.

This job brought to you by eQuest

Type: Full-Time
Location: Orlando, Florida

Job Description:

As one of the nation’s leading pediatric health care systems, Nemours is committed to providing all children with their best chance to grow up healthy. We offer integrated, family-centered care to more than 300,000 children each year in our pediatric hospitals, specialty clinics and primary care practices in Delaware, Florida, Maryland, New Jersey and Pennsylvania. Nemours strives to ensure a healthier tomorrow for all children – even those who may never enter our doors – through our world-changing research, education and advocacy efforts. At Nemours, our Associates help us deliver on the promise we make to every family we have the privilege of serving: to treat their child as if they were our own. 

Nemours is seeking a Pre-Certification Specialist II (Full-Time), to join our Nemours Children's Hospital team in Orlando, Florida.

Located in Orlando, Fla., Nemours Children’s Hospital is the newest addition to the Nemours integrated healthcare system. Our 100-bed pediatric hospital also features the area’s only 24-hour Emergency Department designed just for kids as well as outpatient pediatric clinics including several specialties previously unavailable in the region. A hospital designed by families for families, Nemours Children’s Hospital blends the healing power of nature with the latest in healthcare innovation to deliver world-class care to the children of Central Florida and beyond. In keeping with our goal of bringing Nemours care into the communities we serve, we also provide specialty outpatient care in several clinics located throughout the region.

This position is responsible for obtaining referrals and/or precertifications within 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/precertifications 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 issues 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.

  • Must maintain a professional work relationship with department contacts and other associates.

Job Requirements

  • High School Diploma required.

  • Minimum of one (1) to three (3) years' medical insurance precertification experience required; Florida Medicaid knowledge preferred.

  • Ability to work cooperatively in a team environment required.

  • Ability to communicate effectively verbally and in writing required.

  • Ability to multi-task, prioritize and meet deadlines required.

  • Knowledge of CPT, ICD-9 codes and medical terminology required.

  • Basic knowledge of Microsoft Word and Excel software required.

Our dedication to professionals who are dedicated to children frequently earns Nemours a spot on the list of top workplaces in the communities we serve. Our Associates enjoy comprehensive benefits, including our unique “Bridge to a Healthy Future” pediatric health plan, an integrated wellness program, opportunities for professional growth, and much more. As an equal opportunity employer, Nemours focuses on the best-qualified applicants for our openings.