• 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 the PEAR portal 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 productivity

• 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:

• 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 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 various computer databases required.
• Knowledge of INSINQ is a plus