Pre-Certification Specialist

Position Summary:

The Pre-Certification Specialist verifies patient insurance benefits and secures required authorizations to support the timely and compliant delivery of clinical services at Trinity Health. This role reviews payer guidelines, coordinates closely with clinical departments, and communicates with insurance companies to ensure hospital stays and outpatient services are authorized appropriately. Working as part of a collaborative revenue cycle and care coordination team, the Pre-Certification Specialist helps minimize reimbursement risk by obtaining accurate and complete pre certifications. Through attention to detail, clear communication, and dependable follow-through, this position contributes to efficient operations and supports a positive patient experience by ensuring financial processes are handled promptly and accurately.

Key Responsibilities:

• Verify insurance eligibility and coverage for scheduled and unscheduled services using payer websites, electronic systems, and direct communication with insurance representatives.
• Obtain required authorizations for inpatient admissions, extended stays, outpatient procedures, and diagnostic testing in accordance with each payer’s rules.
• Document authorization details accurately and promptly in the appropriate Trinity Health systems to support billing and clinical workflows.
• Communicate with clinical departments, schedulers, providers, and the Business Office to clarify requirements and resolve authorization-related issues.
• Monitor high-volume workloads, prioritize tasks, and follow up on pending authorizations to ensure timely completion.
• Maintain working knowledge of payer policies, CPT/ICD-10 coding concepts, and medical terminology to support accurate precertification activities.

Licenses and Certifications Required:

• None

Educational Requirements:

• High School diploma or equivalent preferred.

Experience Requirements:

• Experience with third party payer billing regulations, reimbursement requirements, precertification, insurance eligibility verification, and/or utilization management is preferred.
• Working knowledge of CPT/ICD10 and medical terminology is preferred.

Special Skills or Training Requirements:

• Demonstrated advanced communication and interpersonal skills with all levels of internal and external customers.
• Self directed, attention to detail.
• Computer experience.
• Ability to navigate numerous websites for eligibility and prior authorization.
• Working knowledge of Microsoft Office Suite applications including Outlook, Word and Excel.
• Excellent written and oral communication skills.
• Ability to handle high workload volume.
• Must be flexible and demonstrate ability to be adaptable.

Physical Requirements:

The Pre-Certification Specialist primarily works in an office or remote setting requiring prolonged periods of sitting, computer use, and telephone communication. Occasional walking, standing, and light lifting of files or office supplies may be necessary. Adequate vision, hearing, and manual dexterity are essential for reviewing electronic records, entering data, and managing multiple computer applications.

Environmental Requirements:

This position functions in a structured office or remote work environment with frequent interaction with internal departments, insurance payers, and clinical staff. The role involves managing multiple tasks, navigating numerous software systems, and meeting time-sensitive deadlines. The specialist must follow organizational privacy, confidentiality, and data security standards when handling protected health information.