INSURANCE SPECIALIST I

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 submissions
• Prepare 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 teams
• Handle 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 issues
• Keep Senior Insurance Specialist and Leadership team abreast of any payor issues as it relates to authorization and benefits coverage 
• Work with clinical staff of appeal issues 
• Prepare and submit appeal requests to insurance companies, ensuring that all required documentation is complete and accurate. 
• Other duties as assigned.