Insurance Verification and Prior Auth Specialist

Job Description

Job Description

Primary Job Functions[1] :

• Ensures information obtained is complete and accurate, applying acquired knowledge of Medicare, Medicaid, and third-party payer requirements / on-line eligibility systems.
• Contacts insurance carriers to obtain benefit coverage, policy limitations, authorization / notification, and pre-certifications for patients. Follows up with internal departments, physician offices, patients and third-party payers to complete the pre-certification process.
• Identifies out of pocket amounts (i.e., copay, deductible, co-insurance), determining the correct coordination of benefits, identifying if a replacement or supplemental plan exists, identifying termed coverage, and identifying if the patient's plan is considered out of network coverage.
• Collaborates with internal departments to provide account status updates, including expected out of pocket amounts, coordinate the resolution of issues, and appeal denied authorizations.
• Ensures services have prior authorizations and updates patients on their preauthorization status. Coordinates peer to peer review if required by insurance. Notifies ordering providers if authorization / certification is denied.
• May need to coordinate scheduling of patient appointments, diagnostic and / or specialty appointments, tests and / or procedures.
• Maintains files for referral and insurance information, and enters referrals into the system.
• Maintains knowledge of and reference materials of the following : Medicare, Medicaid and third-party payer requirements, guidelines and policies, insurance plans requiring pre-authorization and a list of current accepted insurance plans.
• Runs system-generated reports to verify insurance verification / authorization is being done timely prior to the patient's date of service; verifies the insurance benefits and eligibility either by phone or online for every patient that is scheduled
• Responds to patient calls about how out of network insurance is handled and provide patient with letter explaining this if necessary.
• May need to respond to patient inquiries about their insurance benefits.
• Assists physician’s office staff with any insurance benefit questions and educate them on any changes to the insurance companies’ verification / pre-certification process for the facility.
• Ensures insurance information is verified and entered into the billing system.
• Works with Billing Department to assure all insurance information is entered so claims are not denied. May help research any claim issues.
• Other duties as assigned.

Secondary Job Functions :

Knowledge, Skills and Abilities

Credentials and Experience

Physical Demands

Work Environment

[1] Critical features of this job are described under this heading. They may be subject to change at any time due to reasonable accommodation or other reasons,