Job Description
Job Description
JOB SUMMARY:
The Insurance Specialist I is responsible for completing patient eligibility and benefits checks to determine patient coverage/responsibility for services including, but not limited to primarily major medical insurance benefits verification, complex insurance plan verification, and high volume PBM plans. The Insurance Specialist I needs to understand and work with J-Codes, B- Codes, S-Codes, Diagnosis codes, route of administration, place of service, IPA claims, Medicare B & D billing, Major Medical, and PBM. The Insurance Specialist I will also be responsible for facilitating authorization submittals, follow-ups, and appeals.
QUALIFICATIONS:
- High School Diploma or attainment of a GED through an accredited institution. Two years of college education is preferred.
- 0-3 years of insurance verification and/or pharmacy tech experience in using billing codes, diagnosis codes, route of administration, place of service, IPA claims, Medicare B&D billing, Major Medical, PBM, authorization; OR experience as an Insurance Verifier or similar position with Home Infusion or Specialty Pharmacy.
- 0-2 years of experience in obtaining prior authorizations.
- 0-2 years of experience with the coordination of benefits, secondary insurance, and/ or patient assistance programs.
- Knowledge of and ability to explain concepts of medical benefit plan design (cost-benefit, co-insurance, lifetime benefit, out-of-pocket maximum, using billing codes. CPT codes, and Diagnosis codes/ route of admin /place of service).
- At least 2 years of experience in providing customer service to internal and external customers, including meeting quality standards for services, and evaluation of customer satisfaction.
- Problem-solving experience.
- Willing to work extra hours, outside of normal business hours based on department needs.
- Computer proficiency in standard office applications; i.e. Microsoft Office Suite applications (Word, Excel, PowerPoint, Outlook); ability to learn and master industry-specific software applications such as CPR+.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Verify and validate all insurance benefits for patients by contacting insurance providers via phone, online portals, and other communication channels.
- Obtain and document detailed information on coverage, copayments, deductibles, and any other relevant insurance details.
- Monitor all new referrals throughout the insurance verification process before deadlines.
- Collaborates with healthcare providers to gather necessary information for authorization submissions
- Prepare and submit authorization requests to insurance companies, ensuring that all required documentation is accurate and complete.
- Completing submissions in a timely manner.
- Consistently follow up with the plans on authorization status and communicate back to clinic/internal teams
- Handle incoming and outgoing calls from internal team members, account managers, insurance payers, and clinics related to insurance benefits.
- Effectively communicate with patients, healthcare providers, and insurance companies to address inquiries and provide clarification on benefit verification and authorization processes.
- Collaborate with the Lead Insurance Specialist to escalate and resolve complex issues
- Keep Senior Insurance Specialist and Leadership team abreast of any payor issues as it relates to authorization and benefits coverage
- Work with clinical staff of appeal issues
- Prepare and submit appeal requests to insurance companies, ensuring that all required documentation is complete and accurate.
- Other duties as assigned.