Pre-Certification Specialist Behavioral Health - Remote (PA/NJ/DE)

Independence Blue Cross LLC; Philadelphia (Philadelphia County); Remote; USD 45,000 - 60,000; Full time

Job summary

A major health insurance provider is seeking a Precertification Specialist in Philadelphia to process behavioral health precertification requests. The role involves handling high-volume calls from members and professionals, verifying eligibility, and maintaining departmental standards. Candidates should possess excellent organizational skills, proficiency in Microsoft Office Suite, and customer service experience. A bachelor's degree is preferred but not required.

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.

Responsibilities

• Answers incoming calls regarding precertification requests.
• Verifies member eligibility and participation status.
• Processes precertification requests from members and providers.
• Adheres to departmental standards and quality assurance.

Skills

Excellent organizational skills

Interpersonal skills

Verbal communication

Written communication

Detail oriented

Proficiency in Microsoft Word

Proficiency in Outlook

Proficiency in Excel

Proficiency in SharePoint

Proficiency in Adobe programs

Education

Bachelor's degree preferred

Job description

Overview

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
• 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.