Insurance Verification Specialist

Insurance Verification Specialist

Job Details

Job Location

MCFI Main Campus - Milwaukee, WI

Remote Type

Hybrid

Position Type

Full Time

Education Level

High School Diploma, HSED or GED

Travel Percentage

None

Job Shift

Day

Job Category

Legal

Description

Job Purpose:

The Insurance Verification Specialist provides detailed and timely communication to facilitate compliance with payer contractual requirements and is responsible for documenting the appropriate information in the patient's record. They ensure preauthorization and referral requirements are met before the delivery of system services that require authorization.

Reporting Relationships

Reports To : Director of Business Operations

Direct Reports : No direct reports

Essential Job Functions:

(Reasonable Accommodations may be made to enable individuals with disabilities to perform these essential functions.)

• Demonstrate strong knowledge of insurance requirements, including processing all referrals requiring authorization based on plan and type of referral.

• Initiate contact with/ payers to complete insurance verification activities to prevent delays in care due to missing authorizations.

• Use critical thinking to troubleshoot and contact payers and patients as necessary to secure coverage and authorizations before services are rendered.

• Navigate EHR and insurance portals/protocols associated with each payer for authorization activities, including identifying and providing all relevant clinical information to support the authorization.

• Document all authorization-related information using medical terminology appropriate to the service in the EHR to support continuity of care. This includes information gathered during the verification or authorization process.

• Update health records with/ accurate information regarding insurance coverage based on information gathered during the verification and/or authorization process.

• Obtain required authorizations, pre-certifications, and 2nd opinion approval for outpatient procedures for multiple service lines, departments, and modalities across the continuum. Identify/escalate barriers to obtaining authorization from the insurance company or per department protocol.

• Respond to insurance company inquiries for information. This includes consent, pre-authorization, second opinion, and referral forms.

• Coordinates with/ providers, payers, departments, and patients regarding authorization status and options and documents outcomes in the EHR.

• Confirms payment coverage, including initiating insurance and managed care authorizations.

• Communicate with/ providers and the clinical team to resolve any outstanding information regarding preauthorization and referral requirements.

• Perform electronic eligibility confirmation as needed; verify insurance for encounters and visits as assigned.

• Completes assigned tasks in EHR work queues and brings work lists to completion.

• Generates forms for insurance companies: consent, pre-authorization, second opinion, and referral.

• Notify the provider of the denied procedure/request for peer-to-peer discussion with the insurance company and adjust the authorization status accordingly.

• Works independently and as part of a team in conjunction with Utilization Review and other departments as necessary to provide appropriate clinical information from the EHR to appeal the insurance company's denials and secure financial payments.

• Follow-up on discharge status of patients and relay information to insurance carriers as required.

• Actively participates in identifying/implementing improvements to department/organizational processes to meet business objectives and educate staff efficiently and effectively.

• Accountabilities include completing compliance requirements, achieving productivity standards, and maintaining competency levels/quality standards defined by the organization.

Required Education, Experience, Certifications, Licensure, and Credentials: (Where appropriate, education and/or experience may be substituted)

Minimum Required Education: High School diploma / GED

Minimum Required Experience:

• 3+ years' experience in medical billing, medical insurance verification, managed care, and/or patient registration.

• 3+ years' experience with health insurance plans, including Medicare, Medicaid, and commercial carriers.

• 3+ years' experience working with an EHR system.

• 3+ years of prior authorization experience.

• 3+ years of behavioral health authorization experience.

Required License - Certification - Registration : N/A

Travel outside of the office: N/A

Required Valid Driver's License: N/A

Required Auto Insurance: N/A

Knowledge - Skills - Abilities:

• 1+ years' experience in an acute care billing/insurance verification/managed care/registration department.

• Previous experience with prior authorizations and referrals is strongly preferred.

• Previous experience with MyAvatar Medical is preferred.

• Consistent professional behavior and ability to handle confidential information.

• Demonstrates initiative and is a self-starter.

• Must demonstrate well-developed communication skills - oral and written.

• Excellent customer service and relational skills.

• Able to work independently, prioritizing and organizing workload effectively to complete tasks within the timeframes delegated.

• Must be flexible to handle workflow demands.

Physical Requirements, Visual Acuity, and Work Conditions:

Physical Requirements : Exerting 10-20 pounds of force occasionally. Reaching and extending hand(s) and arm(s) in any direction. Standing for sustained periods. Using Stairs. Walking, moving about on foot to accomplish tasks, pushing, pulling. Lifting, raising objects from a lower to a higher position, or moving objects horizontally from position to position. Picking, pinching, grasping items, typing, or otherwise working. Talking, expressing, or exchanging ideas through the spoken and written word. Hearing and perceiving the nature of sounds at normal speaking levels with or without correction.

Visual Acuity: The worker must have visual acuity to determine the accuracy, neatness, and thoroughness of the work assigned, including preparing and analyzing data and figures, transcribing, viewing a computer terminal, and extensive reading with or without adaptive equipment.

Working Conditions: Work is mainly performed in an office environment utilizing various office equipment including, but not limited to, a personal computer, copy machine, fax machine, and multi-line phone.

This is a general outline of the essential functions of this position and shall not be construed as an all-inclusive description of all work requirements and responsibilities that may be inherent in this position. The employee may be required to perform other job-related duties as requested by the designated work leader(s). All requirements are subject to change over time.