Insurance Specialist

This position is responsible for assuring all appointments and procedures are authorized. Insurance carriers are contacted to verify coverage and benefit limitations, tests and procedures are pre-authorized and scheduled, deductibles, co-payments, account balances, and fees are calculated and notations are added to the system for front end collection. Responsible for minimizing reimbursement errors resulting from inaccuracy of referral and enrollment information.

Minimum Qualifications

• High school diploma or equivalent.
• State criminal background check and Federal (if applicable), as required for regulated areas.
• Previous insurance authorization experience preferred.

CORE DUTIES AND RESPONSIBILITIES

• Identifies all patients requiring pre-certification or pre-authorization at the time services are requested or when notified by another hospital or clinic department.
• Follows up on accounts as indicated by system flags.
• Contacts insurance company or employer to determine eligibility and benefits for requested services.
• Follows up with the patient, insurance company or provider if there are insurance coverage issues in order to obtain financial resolution.
• Uses work queues within the EPIC system for scheduling, transition of care, and billing edits.
• Performs medical necessity screening as required by third party payors.
• Determines referrals/authorization/certification numbers in the EPIC system.
• Initiates charge anticipation calculations.
• Accurately identifies anticipated charges to assure identification of anticipated self-pay portions.
• Communicates with the patient the anticipated self-pay portion co-payments/deductibles/co-insurance, and account balance refers self-pay, patients with limited or exhausted benefits to the in-house Financial Counselors to determine eligibility.
• Assists Patient Financial Services with denial management issues and will appeal denials based on medical necessity as needed.
• Communicates problems hindering workflow to management in a timely manner.
• Maintains current knowledge of major payor payment provisions.

PHYSICAL REQUIREMENTS

• Prolonged periods of sitting.
• Extended periods on the telephone requiring clarity of hearing and speaking.
• Manual dexterity required to operate standard office equipment.

WORKING ENVIRONMENT

• Standard office environment.

SKILLS AND ABILITIES

• Excellent oral and written communication skills.
• Basic knowledge of medical terminology.
• Basic knowledge of ICD-10 and CPT coding, third party payors, and business math.
• General knowledge of time of service collection procedures.
• Excellent customer service and telephone etiquette.
• Minimum typing speed of 25 words per minute.
• Must have reading and comprehension ability.