Pre Certification Coordinator

This position is responsible for coordinating clinical review requests based on benefits, appropriate-ness, and use of national criteria.

  • Take incoming telephone calls from members, providers, hospitals, or primary care physicians.
  • Receive Faxed or written referral requests for clinical review.
  • The Pre-Certification Coordinator performs triage, process intake information, checks eligibility and coverage, and assesses the callers needs; everything from a simple referral for a diagnostic assessment to a need for immediate action, referral to case management, or Medical Director. This position does not make clinical review decisions.
  • Provides assistance to process Level 3 Clinical Medical Review with collecting clinical documentation to support appropriate use of national criteria.
  • Ensures the organization revise all clinical information for Level 3 Medical Director reviews.
  • Ensures compliance with and/or adheres to Company HIPAA policies and procedures.
  • Ensures the integrity of data entered into Company systems and/or database.
  • Ensures Program Integrity for Fraud/Abuse and Exclusions.
  • Ability to safely and successfully perform essential job functions consistent with the ADA, FMLA, and other federal, state, and local standards, including meeting qualitative and/or quantitative productivity standards.
  • Ability to maintain reasonably regular, punctual attendance consistent with the ADA, FMLA, other federal, state, and local standards, and company attendance policies and procedures.
  • Ability to come to work and work the regular schedule and shift for the position.
  • Compliance with all personnel policies and procedures.
  • Perform related duties as assigned.

Other Duties

  • Take incoming telephone calls from members, providers, hospitals, or primary care physicians.
  • Receive Faxed or written referral requests for clinical review.
  • The Pre-Certification Coordinator performs triage, process intake information, checks eligibility and coverage, and assesses the callers needs; everything from a simple referral for a diagnostic assessment to a need for immediate action, referral to case management, or Medical Director. This position does not make clinical review decisions.
  • Provides assistance to process Level 3 Clinical Medical Review with collecting clinical documentation to support appropriate use of national criteria.
  • Ensures the organization revise all clinical information for Level 3 Medical Director reviews.
  • Ensures compliance with and/or adheres to Company HIPAA policies and procedures.
  • Ensures the integrity of data entered into Company systems and/or database.
  • Ensures Program Integrity for Fraud/Abuse and Exclusions.
  • Ability to safely and successfully perform essential job functions consistent with the ADA, FMLA, and other federal, state, and local standards, including meeting qualitative and/or quantitative productivity standards.
  • Ability to maintain reasonably regular, punctual attendance consistent with the ADA, FMLA, other federal, state, and local standards, and company attendance policies and procedures.
  • Ability to come to work and work the regular schedule and shift for the position.
  • Compliance with all personnel policies and procedures.
  • Perform related duties as assigned.

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Education and/or Experience

  • Bachelor's degree or equivalent work experience in data analysis experience.
  • Two or three years background in the managed care industry.

Certificates, Licenses, Registrations

Not applicable to this position.

Supervisory Responsibilities

Not applicable to this position.

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