Precertification Specialist

GTS Scientific; Philadelphia (Philadelphia County); On-site; USD 50,000 - 70,000; Full time

Benefits offered by this job

Parking pass paid for

Job summary

GTS Scientific in Philadelphia seeks a Precertification Specialist to manage prior authorization requests for biologic medications. This role involves collaboration with billing, providers, and insurance companies to ensure efficient access to treatments.

The ideal candidate has experience in authorization processes, a solid understanding of insurance plans, and excellent communication skills. The position is onsite in Center City, Philadelphia, offering a dynamic work environment.

Qualifications

• Experience in managing prior authorization requests for biologic medications.
• Ability to navigate complex payer systems effectively.
• Strong understanding of healthcare workflows related to biologics.

Responsibilities

• Submit and track prior authorization requests for biologic medications.
• Verify insurance benefits and eligibility for specialty therapies.
• Collaborate with providers to obtain necessary clinical documentation.
• Communicate with payers to resolve issues and expedite approvals.
• Educate patients about authorization status.

Skills

Experience in precertification or prior authorization

Knowledge of commercial insurance plans

Familiarity with specialty pharmacy workflows

Strong organizational skills

Proficiency in payer portals

Strong communication skills

Job description

Location: Onsite in Center City, Philadelphia (4 10 hour days) Parking pass paid for

The Precertification Specialist is responsible for managing and processing prior authorization requests for biologic medications, ensuring timely and accurate approvals in compliance with payer guidelines and clinical protocols. This role requires a strong understanding of biologic therapies, insurance requirements, and healthcare workflows

The specialist works closely with Billing Director , providers, patients, insurance companies, and pharmacy teams to facilitate access to high-cost biologic treatments. Attention to detail, excellent communication skills, and the ability to navigate complex payer systems are essential.

Key Responsibilities

• Submit and track prior authorization requests for biologic medications.
• Verify insurance benefits and eligibility for specialty therapies.
• Collaborate with providers to obtain necessary clinical documentation.
• Communicate with payers to resolve issues and expedite approvals.
• Educate patients on authorization status and next steps.
• Maintain accurate records in payer portals.
• Stay updated on payer policies and biologic drug changes.
• Enroll patients in co-pay assistance programs.
• Run Monthly Reports
• Follow-up on denied biologic claims.
• Non-biologic billing tasks as needed.

Key Performance Metrics

• Authorization Turnaround Time: Average time from submission to approval.
• Approval Rate: Percentage of biologic precertifications approved on first submission.
• Denial Resolution Rate: Success rate of overturned denials through appeals.
• Documentation Accuracy: Percentage of submissions with complete and correct documentation.
• Patient Communication Timeliness: Time taken to notify patients of authorization status.
• Compliance Rate: Adherence to payer-specific guidelines and internal protocols.
• Volume Management: Number of precertification cases handled per week/month.

Qualifications

• Experience in precertification or prior authorization, specifically with biologic medications.
• Knowledge of commercial insurance plans.
• Familiarity with specialty pharmacy workflows and biologic drug therapies.
• Strong organizational and communication skills.
• Proficiency in payer portals.
• Ability to work independently and collaboratively.