Position Summary:
The insurance verification representative will be responsible for verifying insurance eligibility and benefits, securing authorizations for hospital services, and coordinating with physician offices and the Patient Assistance Center (PAC) on the pre-financial clearance on elective procedures and diagnostic testing. Our insurance verification representative will be skilled in maintaining effective working relationships with co-workers, third party payors, physician offices, and the PAC while maintaining exemplary customer service skills and passion for quality healthcare. The insurance verification specialist performs insurance verification and benefits information reviews, validates authorizations for hospital services utilizing hospital information systems, payor portals, and other revenue management Patient Access tools. Communicates with the PAC, physician offices, and schedulers when there are issues with authorizations and pre-financial clearance for scheduled procedures and diagnostic testing. Knowledgeable of the principles and practices of healthcare billing, out-of-network benefits, industry and government regulations, and reimbursements. Assists to initiate pre-admission registration, as needed. Confirms medical necessity requirements are met for services. Works closely with the financial counselors.
KEY RESPONSIBILITIES:
- Verifies member eligibility and benefits.
- Inputs all referral requests into the system accurately for electronically generated authorization tracking.
- Requests submission of appropriate medical records according to established criteria for requested service(s).
- Issues authorization within an appropriate timeframe for routine, urgent, and emergent requests.
- Appropriately forwards all referral requests to the next level of review.
- Coordinates approved outpatient procedures with the health plan's authorization department when applicable.
- Distributes correspondence and other information to the appropriate parties or departments.
- Documents and communicates areas of concern to the supervisor.
- Identifies providers who are problematic with plan requirements.
- Adheres to company HIPAA policies and procedures.
- Ensures the integrity of data entry is accurate.
REQUIRED KNOWLEDGE & SKILLS:
- Medical terminology, Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS)/International Classification of Diseases (ICD)-9 coding knowledge.
- Knowledge of medical terminology/anatomy.
- The ability to exercise discretion and make independent judgments, seeking review when decisions represent significant departures from established guidelines.
- Knowledge of Microsoft Office programs including Excel, Word, or similar programs.
- Ability to maintain composure during challenging interpersonal interactions.
- Active listening skills, including interpersonal skills and telephone communication.
- Organizational skills with attention to detail and follow-up.
EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:
Education: High School Diploma or equivalent education/experience.
Experience (Type & Length): One year within a healthcare setting.
Software/Hardware: Meditech.
License/Certification: None.
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