As one of the nation’s leading pediatric health care systems, Nemours is committed to providing all children with their best chance to grow up healthy. We offer integrated, family-centered care to more than 300,000 children each year in our pediatric hospitals, specialty clinics and primary care practices in Delaware, Florida, Maryland, New Jersey and Pennsylvania. Nemours strives to ensure a healthier tomorrow for all children – even those who may never enter our doors – through our world-changing research, education and advocacy efforts. At Nemours, our Associates help us deliver on the promise we make to every family we have the privilege of serving: to treat their child as if they were our own.
The primary function of the Pre-Certification Specialist is to obtain and enter authorizations and request pre-certifications for assigned clinics.Be very familiar with the requirements of all insurance types.Continuously educate self to the specific contract stipulations for each division within Nemours Children’s Clinic.Customer service oriented to both external and internal customers. The hours are Monday through Friday, 8am -5pm
Review, evaluate, verify and process assigned clinics authorizations for office visits, pre-certification requests for Inpatient, Outpatient and Clinic procedures for Nemours’ patients.
Enter all authorization and pre-certification numbers issued into the scheduling system.
Contact insurance companies for pre-certification, at least seven days prior to the patient’s scheduled procedure.
Assist Clinics in obtaining pre-certification for emergency admits and for patients needing same day clinic visit/hospital admit/procedure.
Answer and return calls from clinic personnel regarding authorizations pre-certifications.
Verify patient eligibility and pre-certification requirements through On-line verification software or by telephone.
Maintain open line of communication with clinic personnel.
Communicate with assigned clinics regarding unattainable authorizations.
Assist patients in obtaining an authorization when they arrive at the clinic without an appropriate authorization and advise clinic of patient status.
Workques: Process encounters via the DAG workque daily.
Participate and engage in Continuous Improvement events and projects.
Follow-up with the Insurance plan on requested pre-certifications in a timely manner as determined by insurance, hospital, and NCSC Policy.
Assist Registration and PSS teams when necessary.
Obtain office notes from EPIC or Clinic when needed to obtain pre-certification.
Assist other team members when needed.
Assist Clinic schedulers with same day and next day add-on’s when needed.
Maintain a fourteen day lead on work, prior to scheduled procedure date.
Educate patients, parents, and clinic personnel and provide them with information to assist in obtaining pre-certifications.
Excellent customer service skills
Relays accurate information
Gives and receives feedback
Ability to set priorities and manage time sensitive issues
Ability to work with limited supervisor
Willingness to adapt to change
Recognizes and understands policies and procedures
Must adhere to Standards of Behaviors
at least 1 year of prior experience required
Our dedication to professionals who are dedicated to children frequently earns Nemours a spot on the list of top workplaces in the communities we serve. Our Associates enjoy comprehensive benefits, including our unique “Bridge to a Healthy Future” pediatric health plan, an integrated wellness program, opportunities for professional growth, and much more. As an equal opportunity employer, Nemours focuses on the best-qualified applicants for our openings.
Nemours is a pediatric health system of hospitals and specialty clinics serving children and families throughout the Delaware Valley and Florida. Our dedicated professionals integrate medical care, research, health education, and prevention to help improve the lives of children every day.