Pre-Certification Specialist II (Therapy Services)

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

This is a full-time pre-certification specialist position in our Therapeutic and Rehab Services Department.  The position is mostly remote with occasional requirements to be on-site at Nemours Children's Hospital.

​Located in Orlando, Fla., Nemours Children’s Hospital is the newest addition to the Nemours integrated healthcare system. Our 130-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.

The pre-certification specialist is well versed in billing and coding for therapy services.  They are responsible for obtaining insurance authorizations for therapy services and providing information related to therapy insurance benefits.  They work closely with our schedulers to ensure that patients that are scheduled are approved by insurance. This is a process oriented position in order to allow for efficiency and managing a large volume of patient cases.

The Precertification Specialist II is responsible for obtaining referrals and/or pre-certification for assigned specialties within seven to fourteen (7-14) days prior to the patient's scheduled service. 

The Specialist will ensure:

• insurance has been verified
• referrals and pre-certifications have been obtained and linked to the correct accounts with accurate documentation in the Epic system
• denied referral/precertification requests are communicated to the appropriate areas

Essential Functions

• Knowledge of participating insurances and authorization requirements.
• Responsible for obtaining complete and accurate insurance information and benefits verification.
• Interprets benefit plans and investigates pertinent details.
• Verifies patient eligibility and precertification requirements through online resources or via telephone.
• Effectively communicates 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 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.

Job Requirements

• High School Diploma required.
• Minimum of 1 year of experience performing one or more of the following duties in a health care environment is required; 3 years is preferred.
  • pre-certification, scheduling, admissions, registration, billing, authorization, insurance specialist, financial advocate or healthcare related role.
• Experience in medical insurance precertification and Florida Medicaid knowledge preferred.
• Knowledge of CPT, ICD-10 codes and medical terminology preferred.
• Basic knowledge of Microsoft Word and Excel software required.

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