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

Bring your drive for excellence, team orientation and customer commitment to Independence Blue Cross; help us renew and reimagine our business and shape the future of health care. Our organization is looking to diversify, grow, innovate and serve, and we are looking for committed, empowered learning-oriented people to join our team. If this describes you, we want to speak with you.

Under the direction of a manager and licensed health professionals, the Pre-Cert Specialist processes 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 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 the National Provider Identification(NPI) Registry

Processes precertification requests from members and providers received telephonically, via fax or NaviNet 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 cosmetic and investigative/experimental procedures

Adheres to the departmental standards for staff time, after call work, attendance and non-queue production

Adheres to the corporate quality customer-focused professionalism and accuracy standards

Responds to voicemails and emails within one business day, as necessary

Performs additional duties as assigned

Education and Experience Required:

High school diploma required, associate degree in a related field preferred.

A minimum of three years of customer service experience in the health insurance industry or health services industry strongly recommended including knowledge of medical terminology, a general understanding of managed care delivery systems and a familiarity with ICD9/ICD10 and CPT codes.

Excellent organizational, interpersonal, verbal and written communication skills, necessary

Detailed oriented with an ability to accept and respond to changes.

Experience accessing, navigating, and data entering into computerized databases required. Specifically, Word, Excel, and Mainframe

Knowledge of INSINQ is a plus

Fully Remote:
This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence’s physical office locations to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania.

IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.

Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.