Pre-Certification Specialist Behavioral Health - Remote (PA/NJ/DE)
Under the direction of a Supervisor, Health Resources Center, the Precertification Specialist processes Behavioral Health precertification requests in accordance with established corporate guidelines and in compliance with all state and federal regulations.
Major Activities:
- Answers incoming telephone calls in a high-volume Call Center environment from members and health care professionals regarding requests for precertification of behavioral health services.
- Verifies member eligibility by accessing multiple eligibility systems
- Verifies participation status of professional and facility providers, by product and state utilizing multiple database systems including but limited to the National Provider Identification (NPI) Registry
- Processes precertification requests from members and providers received telephonically, via fax or the Provider portal per department guidelines
- Obtains all clinical information including procedure and diagnosis codes
- Enters all pertinent data in the appropriate computer system
- Approves selected services per departmental guidelines
- Identifies precertification requests that warrant a medical necessity review
- Identifies potentially investigative/experimental procedures
- Obtains all clinical information including procedure and diagnosis codes
- Adheres to the departmental standards for staff time, after call work, attendance, and non-queue productivity
- Adheres to the corporate quality customer-focused professionalism and accuracy standards
- Responds to all forms of communication promptly and as necessary
- Performs additional duties as assigned
Qualifications
- Excellent organizational, interpersonal, verbal, and written communication skills required
- Detail oriented with an ability to accept and respond to change.
- Proficiency utilizing Microsoft Word, Outlook, Excel, SharePoint, and Adobe programs.
- Ability to learn new systems as technology advances
Education and Experience:
- Bachelor’s degree preferred, but not required
- Previous experience in social work or related field recommended
- Previous customer service experience is required
- Previous medical insurance experience is highly recommended, behavioral health experience a plus
- Coding knowledge recommended.
Fully Remote:
This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence’s physical office locations to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania.
IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.
Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.
Inclusion and Belonging
At AmeriHealth Administrators, everyone can feel valued, supported, and comfortable to be themselves, and all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. Celebrating and embracing diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.
About Our Company
AmeriHealth Administrators is one of the largest national third-party administrators providing innovative, value-based health benefits programs and outsourcing services for self-funded health plans and other organizations.
The company also provides customized outsourcing services for TPAs and other payers, student health plans, and fully insured products.
AmeriHealth Administrators serves 1 million plan members in all 50 states and processes over 6 million claims annually.
Equal Employment Opportunity
AmeriHealth Administrators is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.
Agency Disclaimer
All resumes submitted directly to an AmeriHealth Administrators employee from a vendor via email, the Internet or in any other form without a valid written search agreement in place for this position from the Independence Blue Cross Family of Companies Human Resources Department will be deemed the sole property of AmeriHealth Administrators and the Independence Blue Cross Family of Companies. Please note that no fee will be paid in the event the candidate is hired by AmeriHealth Administrators or the Independence Blue Cross Family of Companies as a result of the referral or through means other than our established process.