Pre-Certification Specialist

Job Description

Job Description

Pre-Certification Specialist Job Description

Rehabilitation and Neurological Services LLC

Position Overview

The Pre-Certification Specialist is responsible for obtaining prior authorizations and pre-certification approvals from insurance carriers to ensure timely access to medically necessary services, procedures, medications, diagnostic testing, and specialty treatments. This position plays a critical role in minimizing delays in patient care, reducing claim denials, and ensuring compliance with payer requirements.

The ideal candidate will possess strong organizational skills, attention to detail, and the ability to work efficiently in a fast-paced medical office environment. Experience with neurology-related procedures, spinal injections, joint injections, and knowledge of CPT coding is strongly preferred.

Key Responsibilities

Pre-Certification & Authorization Management

• Obtain prior authorizations and pre-certifications for medical procedures, diagnostic testing, imaging, medications, specialty services, and office-based procedures.
• Verify insurance eligibility, benefits, coverage limitations, and authorization requirements.
• Submit complete and accurate clinical information to insurance carriers to support medical necessity.

Procedure Knowledge & Coordination

• Demonstrate preferred knowledge of spinal injections, joint injections, pain management procedures, neurology-related services, and associated payer requirements .
• Understand procedure-specific authorization guidelines and medical necessity criteria.
• Coordinate with providers and clinical staff regarding procedure scheduling pending authorization approval.

CPT Coding & Documentation

• Maintain working knowledge of CPT, ICD-10, and HCPCS coding , with preferred experience interpreting CPT codes related to spinal and joint injection procedures .
• Review physician orders, clinical documentation, and coding information to ensure authorization accuracy and completeness.
• Ensure all supporting medical records and documentation meet insurance and regulatory standards.

Communication & Coordination

• Serve as a liaison between healthcare providers, insurance companies, patients, and clinical staff to facilitate efficient authorization processing.
• Communicate authorization statuses, denials, and additional documentation requirements to appropriate team members.
• Educate patients, when appropriate, regarding insurance authorization requirements and scheduling delays.

Follow-Up & Denial Management

• Track and follow up on pending authorization requests to ensure timely approvals and avoid disruptions in patient care.
• Investigate, appeal, and assist in resolving denied or delayed authorization requests.
• Maintain detailed records of authorization statuses, reference numbers, and payer communications.

Data Entry & Record Maintenance

• Accurately enter and maintain authorization and pre-certification information within the Electronic Health Record (EHR) and other applicable systems.
• Maintain organized records of approvals, denials, expiration dates, and payer requirements.

Compliance & Regulatory Awareness

• Stay current on insurance policies, payer updates, prior authorization requirements, and regulatory guidelines.
• Ensure compliance with HIPAA, payer regulations, and organizational policies and procedures.

Qualifications

Education

• High School Diploma or equivalent required.
• Associate’s or Bachelor’s degree in Healthcare Administration, Medical Billing & Coding, Business Administration, or a related healthcare field preferred.

Experience

• Minimum of 2–3 years of experience in a healthcare, medical office, or insurance setting with a focus on prior authorizations, pre-certification, or insurance verification preferred.
• Neurology, pain management, orthopedic, or specialty medical office experience preferred.

Skills & Knowledge

• Strong knowledge of insurance pre-certification, prior authorization, and payer requirements .
• Preferred knowledge of spinal injections, joint injections, and specialty procedure authorization workflows .
• Working knowledge of CPT, ICD-10, and HCPCS codes, with preference given to candidates familiar with injection-related CPT coding.
• Strong attention to detail and organizational skills.
• Excellent communication and interpersonal skills.
• Proficiency in Electronic Health Records (EHR) and medical office software.
• Ability to multitask, prioritize, and work independently in a fast-paced environment.

Preferred Certifications

• Certified Professional Coder (CPC) preferred but not required.
• Medical billing and coding certification is a plus.

What We Offer

• Competitive salary and benefits package
• Health, dental, and vision insurance
• Retirement savings plan with company match
• Opportunities for professional development and growth
• Supportive, team-oriented work environment