Insurance Specialist

POSITION DESCRIPTION

POSITION SUMMARY: Insurance Specialist is responsible for assuring all appointments and procedures are authorized. Insurance carriers are contacted to verify coverage and benefit limitations. Tests and procedures are pre-authorized and scheduled. Deductibles, co-payments, account balances, and fees are calculated and notations are added to the system for front end collection. Responsible for minimizing reimbursement errors resulting from inaccuracy of referral and enrollment information.

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

High school graduate or equivalent.

Minimum typing speed of 25 works per minute

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

Identifies all patients requiring pre-certification or pre-authorization at the time services are requested or when notified by another hospital or clinic department

Follows up on accounts as indicated by system flags

Contacts insurance company or employer to determine eligibility and benefits for requested services

Follows up with the patient, insurance company or provider if there are insurance coverage issues in order to obtain financial resolution

Use work queues within the EPIC system for scheduling, transition of care, and billing edits

Performs medical necessity screening as required by third party payors

Documents referrals/authorization/certification numbers in the EPIC system

Initiates charge anticipation calculations. Accurately identifies anticipated charges to assure identification of anticipated self-pay portions.

Communicates with the patient the anticipated self-pay portion co-payments/deductibles/co-insurance, and account balance refers self-pay, patients with limited or exhausted benefits to the in-house Financial Counselors to determine eligibility

Maintains current knowledge of major payor payment provisions and regulations

Assists Patient Financial Services with denial management issues and will appeal denials based on medical necessity as needed

Ability to accurately utilize applicable computer software and equipment for access processing

Demonstrates ability to follow established computer down time procedures.

Participates in educational programs to meet mandatory requirements and identified needs with regard to job and personal growth.

Follows established work systems, identifies deviations or deficiencies in standards/systems/processes and communicates problems to supervisor or manager)

Maintains confidentiality according to policy when interacting with patients, physicians, families, co-workers and the public regarding demographic/clinical/financial information.

Is polite and respectful when communicating with staff, physicians, patients and families. Approaches interpersonal relations in a positive manner.

Uses hospital communications systems (fax, pagers, telephones, copiers, scanners, and computers) in accordance with hospital standards

Communicates problems hindering workflow to management in a timely manner.

Assesses all self-pay patients for potential public assistance through registration/billing systems Provides self-pay/under-insured patients with financial counseling information. Maintains current knowledge of major payor payment provisions.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Prolonged periods of sitting required

Extended periods on the telephone requiring clarity of hearing and speaking

Manual dexterity required to operate standard office equipment

Must have manual dexterity to operate keyboards, fax machines, telephones and other business equipment

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Outpatient clinical environment

Excellent oral and written communication skills

Basic knowledge of medical terminology preferred

Basic knowledge of ICD-10 and CPT coding preferred

Basic knowledge of third party payors preferred

Basic knowledge of business math preferred

General knowledge of time of service collection procedures preferred

Excellent customer service and telephone etiquette

Must have reading and comprehension ability

Date Reviewed/Revised: August 2017