Surgical Pre-Certification Specialist

Published: 6/14/2022

Education

Job Description

Location: 9 Washington Place, Bedford, NH
Schedule: Monday–Friday, 8:30 AM–5:00 PM
Pay Status: Hourly, Non-Exempt
Work Setting: Full-Time, In Office

Position Summary

The Surgical Pre-Certification Specialist is responsible for verifying insurance eligibility and benefits and obtaining timely prior authorization for surgeries, procedures, and related services. This role works closely with Surgery Coordinators, clinical teams, providers, and other departments to ensure authorization requirements are met prior to the scheduled date of service.

The Specialist is responsible for reviewing surgical bookings, submitting and tracking authorization requests, maintaining accurate documentation, and communicating authorization status, payer requirements, delays, and denials to the appropriate teams. Strong attention to detail, organization, follow-through, and the ability to manage multiple cases and deadlines are essential.

Key Responsibilities

Work closely with Surgery Coordinators, clinical teams, providers, and other departments to obtain orders, clinical documentation, procedure information, and other materials required for surgical pre-certification.
Verify insurance coverage, eligibility, benefits, patient demographics, and payer information in the practice management system.
Confirm procedure and diagnosis codes and obtain all information required by the payer to ensure services are authorized and eligible for payment.
Obtain and document prior authorizations for surgical procedures and related services in accordance with payer requirements and established timelines.
Review surgical bookings for completeness and accuracy, including patient information, insurance plan, provider, facility, date of service, and procedure and diagnosis codes.
Submit authorization requests through payer portals, by telephone, or by fax and provide supporting clinical documentation when required.
Track pending authorization requests and follow up consistently until an approval, denial, or request for additional information is received.
Document authorization numbers, effective dates, approved services, payer contacts, reference numbers, and supporting notes in the appropriate system.
Communicate authorization status, payer requirements, delays, and denials promptly to Surgery Coordinators, clinical staff, providers, and leadership.
Escalate urgent cases, peer-to-peer review requests, authorization concerns, and potential service delays to the appropriate clinical or operational leader.
Assist with authorization-related denials, appeals, and retrospective requests by gathering documentation and coordinating follow-up as directed.
Reverify insurance coverage and authorization when a procedure, date, location, provider, insurance plan, or procedure/diagnosis code changes.
Maintain work queues and meet established productivity, accuracy, and turnaround-time expectations.
Maintain patient confidentiality and comply with HIPAA, payer requirements, and company policies and procedures.
Provide professional and courteous service to patients, coworkers, providers, facilities, and insurance representatives.
Perform other related duties as assigned by management.

Qualifications

High school diploma or equivalent required; additional education in medical billing, coding, or healthcare administration preferred.
Previous medical office, surgical scheduling, insurance verification, or prior authorization experience preferred.
Knowledge of medical terminology, insurance eligibility, prior authorization processes, and basic CPT/ICD-10 coding preferred.
Strong attention to detail, organization, follow-through, and ability to manage multiple cases and deadlines.
Excellent written and verbal communication skills and a professional telephone manner.
Ability to work independently and collaboratively in a fast-paced, fully in-office environment.
Proficiency with electronic health records, practice management systems, payer portals, Microsoft Office, and standard office equipment.
Orthopaedic experience preferred.

Physical Requirements

Primarily sedentary work performed in an office setting. Prolonged sitting and frequent computer and telephone use are required. Must be able to communicate clearly, manage frequent interruptions, maintain focus, and handle detailed information and deadlines.