Pre-Certification Coordinator

Position Summary

The Pre-Certification Coordinator is responsible for verifying patient insurance coverage, obtaining required referrals, prior authorizations, and pre-certifications for medical services, procedures, and treatments. This role serves as a liaison between patients, providers, insurance carriers, and billing teams to ensure timely authorization, accurate documentation, and clear communication regarding insurance benefits and financial responsibility.

Key Responsibilities

• Verify and document patient insurance coverage and benefits to determine eligibility for physician visits, diagnostic testing, surgical procedures, and other healthcare services.
• Obtain required referrals, pre-certifications, and prior authorizations for hospitalizations, surgeries, diagnostic procedures, treatments, and physician services in accordance with payer requirements.
• Communicate patient insurance benefits, coverage limitations, and estimated out-of-pocket expenses for scheduled procedures and services.
• Accurately document insurance verification, authorization approvals, referrals, and financial arrangements within the electronic medical record and applicable databases.
• Prepare, submit, and monitor pre-determination requests with insurance carriers and follow up on authorization status and responses.
• Collaborate with billing services to address account discrepancies, provide insurance updates, and ensure timely reimbursement and accurate patient billing.
• Support financial assistance initiatives by partnering with management, social workers, and care teams to identify patients who may qualify for assistance programs and facilitate the application process.
• Serve as a resource to physicians, clinical staff, and administrative personnel regarding insurance requirements, authorization processes, and billing-related questions.
• Respond to patient inquiries regarding insurance coverage, billing concerns, and financial responsibilities while coordinating resolution with appropriate departments.
• Maintain compliance with organizational policies, payer guidelines, and regulatory requirements.
• Perform additional duties and special projects as assigned.

Minimum Qualifications

Education

• High school diploma or equivalent required.

Experience

• Minimum of two years of experience in healthcare insurance verification, prior authorization, billing, coding, patient access, or a related healthcare revenue cycle function.

Knowledge, Skills, and Abilities

• Knowledge of healthcare insurance plans, benefits verification, referral management, pre-certification, and prior authorization processes.
• Working knowledge of CPT, ICD-10, and HCPCS coding systems.
• Understanding of medical terminology and healthcare reimbursement practices.
• Proficiency with Microsoft Office applications, including Word and Excel.
• Experience using Epic or similar electronic medical record (EMR) systems.
• Strong verbal and written communication skills.
• Excellent organizational, customer service, and problem-solving abilities.
• Strong attention to detail and ability to manage multiple priorities in a fast-paced environment.

Preferred Qualifications

• Certified Coding Specialist (CCS) or related coding certification preferred.
• Experience within a physician practice, hospital, ambulatory surgery center, or healthcare system preferred.
• Additional experience in revenue cycle, patient financial services, insurance authorization, or healthcare billing functions preferred.

Core Competencies

• Insurance Verification & Benefits Coordination
• Prior Authorization & Pre-Certification Management
• Medical Billing & Coding Knowledge
• Patient Financial Counseling
• Revenue Cycle Support
• Healthcare Reimbursement Processes
• EMR Documentation & Data Accuracy
• Customer Service & Patient Advocacy
• Cross-Functional Collaboration