Job Title: Biologics Pre-cert Representative 

Department: CBO

Reports To: CBO Manager

Position Summary

This position is responsible for Pre-Authorization/Pre-Certification or Pre-Determination for Biologics Division

Essential Duties & Responsibilities

• Maintains, prioritizes and works order inbox TASK according to incoming dates timely.

• Reviews incoming orders for completeness, ensuring that all documentation has been received/scanned (i.e. SMN, PAN and insurance benefits from applicable clinics and/or 3rd parties. 

• Reviews orders to determine if biologic will be covered by insurance per clinical payer policy

• Initiates pre-auth, pre-cert or pre-d as per payer requirements to insurance company

• Ensures all information is on tracking spreadsheet with most current status

• Ensures timely follow-up with insurance and timely approvals are obtained

• Once insurance approves or denies-communicates information immediately via TASK response to clinic to ensure timely scheduling or notification to patient

• If needed, will facilitate peer to peer with ordering physician

• Completes follow-up with physicians for final outcome of peer to peer if applicable in a professional manner.

• Monitor order statuses to ensure timely processing and completion.

• Assists with any denied claims to resolve any issues.

Other Duties

• May assist with scheduling as needed; including contacting patients to explain benefits and/or copay card options.

• Submit EOBs and process copay card transactions up to and including posting.

• Assist CBO with medical necessity requests for denied claims

• Attends all meetings related to biologics when requested

Qualifications

EDUCATION AND EXPERIENCE

• High school graduate or equivalent

• 2 years of related experience preferred; related education can be substituted for experience

• Knowledge of health insurance

• Experience working with Electronic Response Admittances (ERAs) and Explanation of Benefits (EOBs)

• Must be self-directed and able to work independently

• Attention to detail and focus a must

• Professional, calm and courteous demeanor

• Excellent verbal and written communication skills

COMPUTER SKILLS

• Proficient computer skills and 10-key by touch

• NextGen a plus

Knowledge, Skills, Abilities

SPECIFIC REQUIREMENTS:

• Pre-certification knowledge/experience, particularly for injectable biologics preferred

• Prior experience with patient scheduling or working in a medical clinic preferred

• Previous billing, Medicare and private pay experience preferred

• Knowledge of CPT, HCPCS and some knowledge of ICD-10 codes (with ability/willingness to adapt to ICD-10 codes) preferred

• Familiarity with Medical Terminology preferred

• Proven customer service skills

• Able to work in a high volume/fast-paced environment

• Ability to work with sensitive and confidential information

• Operating knowledge of personal computers and MS Windows applications (including Word, Excel and Outlook)

• Capable of a flexible work schedule, including on-call and overtime hours as needed

• Must be able to interact with patients, insurers and AENT team members and physicians in a responsible, professional and ethical manner

• Must be able to function effectively in a team-oriented environment

• Must be able to work independently with limited direction

• Must be reliable and demonstrate sound judgment and initiative

• Possess a high degree of accuracy in work output

Physical Demands

• Physical Activity Level: Sedentary physical activity performing non-strenuous daily activities of an administrative nature

• Physical Demands: Exerting up to 10 pounds of force occasionally to lift, carry, pull, or otherwise move objects; Substantial movements (motion) of the wrist, hands, and/or fingers in a repetitive manner

Work Environment

Well-lighted, heated and/or air-conditioned indoor office setting with adequate ventilation; Moderate noise (examples: business office with computers and printers, light traffic), daily stair climbing; Typical schedule is Monday through Friday with regular working hours; Occasional overtime may be required.

FULL-TIME Position