Precertification Counselor

Job Description

Job Description

The Precertification Counselor responsible for accurately and efficiently capturing all assigned provider’s surgical cases scheduled, verifying the patient’s surgical benefits, and obtaining all necessary pre-authorizations, pre-determinations, and pre-surgery deposit collections due for each surgery while meeting and exhibiting standards of excellence in customer service.

Key Responsibilities :

• Communicates with patients over the phone in a professional and customer service oriented manner.
• Communicates effectively with staff, secretaries, and physicians by phone or in writing.
• Captures the surgical procedure for assigned physician(s) and becomes the record owner.
• Verifies benefit coverage, eligibility for assigned surgical procedures prior to surgical / procedure date.
• Ensures assigned physician’s surgical / procedure pre-certifications, pre-determinations, and pre-surgery deposit collections due are completed in a timely manner.
• Ensures all scheduled surgical procedures, retro authorizations and ER cases are worked timely to ensure all cases are pre-authorized within the allotted timeframe.
• Determines whether the patient’s insurance company requires pre-authorization or pre-determination and obtains all authorizations, if applicable.
• Able to identify the differences when a prior authorization or a referral is needed prior to the surgical / procedure date.
• Identifies, reviews, extracts, and provides clinical notes, diagnostic testing results, duration and response to conservative therapy measures from patient’s visits to the insurance carrier in an effort to obtain a secure prior authorization for surgical / procedure services.
• Able to utilize medical necessity guidelines for each procedure assigned. Able to recognize missing medical necessity require prior to case submission to insurance company.
• Ensures the nature and outcome of the contact with the insurance carrier of each surgical / procedure requested is documented in specific Florida Orthopaedic Institute programs being utilized within the department to support claims billing and reimbursement of surgical / procedure services.
• Establishes a good working relationship with Primary Care Physician’s office, Insurance and the various Hospitals and surgery centers.
• Maintains a thorough understanding of all major insurance carriers benefit verification and authorization processes. Keeps current with updates for various health plans.
• Maintains and utilizes online access to major insurance carriers.
• Ensure all avenues are identified prior to surgical procedure date to ensure all cpt codes are payable with the insurance company.
• Keeps patient, provider, provider assistant and facility educated on the prior authorization status of the pre-authorization of the case in advance.
• Must ensure excellent communication with providers assistant regarding surgical authorization status to prevent reschedule / cancellation of scheduled surgical date.
• Obtains the insurance company’s contracted rates.
• Calculates the patient’s financial responsibility.
• Collects the patient’s pre-surgery deposit.
• Completes and submits all non-payment letters.
• Completes Physician’s instructions on non-payment letters.
• Communicates effectively with staff, secretaries, physicians and patients.
• All other duties as assigned

About You :

We Would Love It If You Also Had :

At FOI our goal is to provide our patients with world-class orthopedic care.

Our mission of providing the best care encompasses not only the care the physician provides, but all medical and administrative aspects of the patients encounter with Florida Orthopaedic Institute (FOI) as well. Every staff member plays a vital role in this mission. We take pride in receiving the Patriot Award from the Department of Defense for the support that we give to National Guard and Reserve members who are employed by FOI. We are committed to encouraging a culture of inclusion reflective of the communities we serve, and we provide equal opportunity to all. Florida Orthopaedic Institute conforms to the spirit as well as to the letter of all applicable laws and regulations.

What we offer :