Job Description

The Precertification Counselor - Surgical plays a vital role in ensuring that all scheduled surgical procedures are financially and clinically cleared to proceed as planned. This includes managing insurance benefit verification, prior authorization, denial review, communication with vendors and clinical teams, and financial coordination. The coordinator's primary goal is to eliminate preventable causes of same-day surgical cancellations by maintaining a forward-looking 2 plus week review process..

Qualifications

• High School Diploma required
• Five (5) years’ experience in the healthcare setting specifically in benefit verification, prior authorization, or revenue cycle operations.

Key Responsibilities

Preoperative Case Review & Surgical Risk Mitigation:

• Review all upcoming surgical procedures to ensure insurance and clinical requirements are met well in advance of the surgery date.
• Confirm all necessary prior authorizations are submitted and approved, in alignment with payer requirements.
• Ensure surgical benefit verifications are accurate and reflect patient financial responsibility.
• Monitor for medical necessity documentation and address deficiencies that may impact approval or payment.
• Coordinate peer-to-peer (P2P) reviews as needed, and track resolution of any pending or denied cases.
• Maintain a minimum 2-week forward looking window to identify and resolve risks to scheduled procedures in a proactive and timely manner.

Vendor Communication and Authorization Tracking:

• Maintain ongoing communication with third-party vendor responsible for benefit verification and prior authorization.
• Ensure vendor(s) initiates verification and authorization processes no later than 30 days prior to the surgical procedure.
• Escalate any vendor-related delays and work collaboratively to ensure timely clearance of all cases.

Clinical Team Communication & Coordination:

• Conduct weekly meetings with provider’s Administrative Assistant, PA, or ARNP to review surgical schedules, documentation status, and outstanding risks.
• Maintain regular, ongoing communication with admin staff outside of scheduled meetings to ensure timely updates, resolution, and smooth case progression.

Pre-Surgery Deposit Collection Monitoring:

• Identify all cases that require pre-surgical patient financial deposits.
• Ensure that deposit collections are completed by the 14-day deadline prior to the scheduled surgery.
• Collaborate with the billing team and administrative assistants to follow up with patients on outstanding deposits.
• Flag any financial clearance risks early to avoid cancellations due to non-payment.

Denial Management and Documentation Follow-Up

• Track all authorization and medical necessity denials, to coordinate timely resolution efforts including appeals and submission of additional documentation as needed.
• Ensure that peer-to-peer scheduling adheres to established timelines to support prompt case resolution and prevent surgical cancellations for assigned specialties.
• Analyze denial trends and exercise judgment to recommend solutions to workflow improvements aimed at reducing recurrence and optimizing surgical case clearance.
• All other duties assigned.

At FOI our goal is to provide our patients with world-class orthopedic care.

Our mission of providing the best care encompasses not only the care the physician provides, but all medical and administrative aspects of the patients encounter with Florida Orthopaedic Institute (FOI) as well. Every staff member plays a vital role in this mission. We are committed to encouraging a culture of inclusion reflective of the communities we serve, and we provide equal opportunity to all. Florida Orthopaedic Institute conforms to the spirit as well as to the letter of all applicable laws and regulations.

What we offer:

• Full time opportunities available, with room for career growth and advancement.
• Excellent job security and stability, to promote an optimal work life balance.
• Be part of this dynamic and growing Precertification team!

Orthopaedic Solutions Management is a Drug Free Workplace

We are committed to maintaining a safe, healthy, and productive work environment. As part of this commitment, we operate as a drug-free workplace. All candidates will be required to undergo pre-employment drug screening and/or be subject to random drug testing in accordance with applicable laws and company policy.