Patient Care America
INSURANCE SPECIALIST I
Patient Care America, Pompano Beach, Florida, us, 33072
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 submissionsPrepare 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 teamsHandle 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 issuesKeep Senior Insurance Specialist and Leadership team abreast of any payor issues as it relates to authorization and benefits coverageWork with clinical staff of appeal issuesPrepare and submit appeal requests to insurance companies, ensuring that all required documentation is complete and accurate.Other duties as assigned.
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 submissionsPrepare 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 teamsHandle 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 issuesKeep Senior Insurance Specialist and Leadership team abreast of any payor issues as it relates to authorization and benefits coverageWork with clinical staff of appeal issuesPrepare and submit appeal requests to insurance companies, ensuring that all required documentation is complete and accurate.Other duties as assigned.