Customer Service Specialist (Philadelphia)

Precertification Specialist

Location : Remote (must reside in PA, NJ, or DE)

Contract Duration : 36 months

Position Summary

Under the direction of a Supervisor, the Precertification Specialist is responsible for processing precertification requests in compliance with corporate guidelines, state and federal regulations, and departmental quality standards. This is a high-volume, non-clinical call center position requiring strong multitasking skills, accuracy, and professionalism while interacting with members and healthcare providers.

Key Responsibilities

• Handle incoming calls in a high-volume call center from members and healthcare professionals regarding precertification of health services.
• Verify member eligibility, precertification requirements, and provider participation status using multiple systems, including the National Provider Identification (NPI) Registry.
• Obtain and accurately record clinical information, including procedure and diagnosis codes.
• Process precertification requests received via phone, fax, or the PEAR portal per departmental guidelines.
• Approve selected services per departmental policies; escalate cases requiring medical necessity review or those identified as potentially cosmetic or experimental.
• Maintain adherence to departmental standards for staff time, attendance, accuracy, and professionalism.
• Respond promptly to voicemails and emails (within one business day) and ensure complete documentation in the system.
• Support team goals by meeting performance standards for efficiency, accuracy, and customer satisfaction.

Qualifications