Job Description

Precertification Specialist

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

Contract Duration: 3–6 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

• Education: High school diploma required; Associate’s degree preferred.
• Experience in a customer service, call center or provider office setting preferred.
• Familiarity with medical terminology, ICD-10 and CPT codes, and managed care processes.
• Proficient with Microsoft Office Suite and adept at navigating multiple computer systems and databases.
• Excellent communication, interpersonal, and organizational abilities.
• Strong attention to detail, adaptability, and commitment to quality service.

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