Insurance Verifier

About the role

The Insurance Verifier provides timely and accurate insurance verification, obtaining current eligibility, benefit coverage, and authorizations to supply the data needed for prompt reimbursement. The position identifies reimbursement resources for patient care and maximizes efforts to capture them, determines patient responsibilities, insurance reimbursement, and other third‑party reimbursement sources, and applies working knowledge of contracts to interpret per diem rates, case rates, and stop‑loss provisions for accurate reimbursement. The verifier maintains effective working relationships with coworkers, case management, outside companies, and visitors using guest‑relation techniques while representing the vision and values of AHMC‑ARMC, and works closely with patient service representatives to review their work for accuracy and assist with their duties.

Responsibilities

• Support the mission, core values, strategic plan, and performance‑improvement goals of AHMC‑Anaheim Regional Medical Center and AHMC Inc., including customer service, patient rights, confidentiality, environment of care, and organizational initiatives.
• Apply infection‑control policies, standard precautions, disease‑specific isolation, safe sharps handling and disposal, and ensure sterility of supplies and equipment.
• Meet population/age‑specific competencies per unit addendum; attend department education, in‑services, staff meetings, and mandatory training; submit required paperwork on time; verify attendance at meetings or review of minutes.
• Participate in department performance‑improvement projects, assist in unit monitoring, and apply the PDSA model and performance‑improvement principles.
• Understand hospital contracts and all payer types (HMO, PPO, POS, EPO, government payers); interpret patient financial responsibility.
• Provide timely, accurate insurance verification: obtain eligibility, benefit coverage, authorization, and tracking numbers for inpatients, outpatients, and direct admissions.
• Secure authorizations, pre‑certifications, and tracking numbers as required; report registrations to pre‑certification review companies and medical groups/IPAs.
• Identify problems such as outpatient vs. inpatient procedures, potential denials, low benefits, non‑covered services, and analyze factors to determine need for follow‑up; refer issues to Case Management, Manager, Patient Advocates, or Supervisor.
• Interpret per diem rates, case rates, and stop‑loss provisions for accurate reimbursement; document insurance coverage, authorization numbers, and billing data in financial/registration systems.
• Maintain clear, concise documentation of reimbursement status on all accounts; notify manager/supervisor of problem accounts.
• Determine correct billing destination (IPA vs. Plan) and verify billing addresses; perform quality completeness reviews and error checks on accounts.
• Review admissions/registrations for accuracy: service code, patient type, diagnosis spelling, missing diagnoses, insurance payer codes, and all registration fields.
• Collaborate daily with patient advocates on insurance/benefit issues; work with supervisor to identify deficiencies and process improvements.
• Reconcile prior‑day activity against census, surgery, and ancillary schedules; reconcile all accounts against registration reports.
• Maintain professional, courteous communication with coworkers, case management, nurses, physicians, and hospital staff; use proper telephone etiquette under pressure.
• Manage upset or distressed patients, resolve issues within scope, and ensure patients feel cared for and willing to follow procedures.
• Organize workflow, follow up on missing authorization numbers, and communicate effectively in written and verbal form.
• Perform assigned projects, clerical duties, and other related tasks; capable of performing patient registration and explaining/admitting documents.

Qualifications

• High school graduate or GED equivalent preferred
• Minimum 3–5 years admitting/registration and/or business office experience
• General knowledge of third‑party payers: PPO, HMO, POS, EPO, workers’ compensation, Medicare, Medi‑Cal, Cal‑Optima preferred
• Knowledge of insurance authorization, tracking, and pre‑certification preferred
• Bilingual English/Spanish preferred
• Positive work ethic; excellent interpersonal skills; effective communication
• Strong organizational skills
• Computer and typing skills preferred
• Medical terminology preferred