Insurance Verification Representative

Job Description:

This position is responsible to assess insurance eligibility and benefits information and obtain required authorizations and medical necessity to ensure financial viability. Reviews all insurance eligibility responses for completeness. Achieves evaluation of reimbursement based on known factors. Communicates with the patient and their physician as needed regarding these responses or to obtain correct information. Collaborates with primary and /or secondary physician practices, discharge planners, intake staff, and others to ensure authorizations cover services needed and appropriate medical necessity documentation has been obtained to support the need for ongoing services. May also estimate cost of service and patient's responsibility, and analyzes and documents the patient's account history. Refers patients with questionable insurance coverage to the Eligibility Counselors. May assist in mentoring new hires.

Schedule - This position will be required to work Monday - Friday 10:30am– 7:00pm with rotating Saturdays and some holidays.

• Obtains insurance eligibility and benefit information using various phone and on-line resources. Maintains appropriate authorizations and notifies insurance companies of patient arrival as needed. Ensures eligibility and authorization requirements are completed within the required timeframe.
• Ensures clinically appropriate documentation is received timely from medical providers / facilities, to ensure medical necessity is appropriate for type of services being provided. Ensures reauthorization functions are completed in a timely manner, based on individual payer requirements.
• Performs translation of narrative diagnoses provided by physicians into appropriate ICD-9 codes.
• Ensures ongoing eligibility based on clinical documentation for medical necessity. Ensures written order from ordering physician is received, signed, and dated appropriately prior to allowing the account to move to billing (regulatory HC requirement).
• Collaborates with clinicians and intake managers to minimize risk associated with medical necessity / financial sponsorship changes that affect the reimbursement. Makes appropriate corrections in the patient's record to ensure accuracy in order to prevent denials and/or problems with billing and reimbursement.
• Immediately refers 'at risk' services to clinical operations and PAS management, i.e., out of network, underinsured, max benefits, to assist with providing appropriate service for appropriate costs, etc. Works with insurance eligibility responses and other appropriate reports, and works with physicians and patients as needed to resolve issues and prevent billing delays.
• Maintains a satisfactory level of performance and adherence to workload standards.
• Estimates cost of service using ICD-9 or CPT codes. Performs calculations using insurance benefit information to accurately estimate patient responsibility. Analyzes patient / guarantor's previous account history to guide financial conversation.
• May lead and/or train new employees in account preparation and review functions.

PAP Team:

• Communicates with all referral sources, gathers and inputs intake information into the computer system to complete the intake process. Verifies that the physician has provided a complete order. Interfaces with third party payer to determine insurance benefits / authorization at time of intake.
• Assists in the processing of PAP orders for all HME Store Locations. Accurately completes and/or updates the patient's record to ensure all demographic and financial information is correct.

PAP Team Lead:

• Oversees the daily operation of the PAP team including communication with customers and referral sources in all aspects of their prescribed PAP therapy.
• Measures and monitors the productivity of the PAP team member to ensure accuracy and efficiently of all orders received.

Minimum Qualifications

• Demonstrated ability to communicate orally and in writing.
• Experience with basic computer skills to include word processing, email, and spreadsheet
• Two years of customer service experience
• Complex problem solving experience.
• Experience working in a regulatory environment.
• Demonstrated ability to communicate and problem solve issues professionally and effectively with individuals at all levels of an organization.

Preferred Qualifications

• Bilingual Spanish speaking
• Admitting, billing, collection, or insurance verification experience
• Versed in CPT/HCPCS/ICD-9 Codes
• Medical Terminology
• Experience with government healthcare requirements
• PAP Team: HME PAP processing experience

Physical Requirements: