Benefit Authorization/Verification Specialist

Summary: The Benefit Authorization/Verification Specialist  is responsible for benefit verification, negotiation, and/or pre-authorization processing of contracted payors, group health, Medicare, managed care, workers’ compensation, personal injury and/or governmental payor patient referrals consistent with corporate policy and procedure. The essential responsibilities are typically a variety of projects of significant scope and complexity, difficult, & demanding, and the incumbent may be required to apply specialized knowledge of functional areas to modify existing methods, solve problems, and complete tasks. Work is typically performed under general direction. Work is subject to periodic review upon completion and is typically performed under general direction.

Essential Duties and Responsibilities:

Work new orders promptly: All orders received by 12:00 pm PT should be processed on the same day (Monday-Friday, excluding holidays),

Review and confirm documentation: Ensure all medical records and prescriptions meet company guidelines and payor standards for medical necessity.

Insurance verification and prior authorization: Verify insurance benefits and initiate prior authorization when necessary.

Communicate with adjustors: Confirm active claims, accepted body parts, preferred vendors, required documents, and contact information.

Maintain positive patient relationships: Develop and sustain professional relationships, communicate effectively, and manage patient expectations.

Initiate patient communication: Complete introductory calls within 24 hours of receiving orders to discuss authorization, benefits, co-pays, and timelines with patients.

Provide product information: Emphasize product features, quote prices, discuss payment options, and explain insurance coverage for third-party reimbursement.

Coordinate payment plans: Assist patients with specialized co-payments, deductibles, and payment plans.

Stay updated and implement improvements: Stay informed about industry changes, implement process improvements, and meet department and company goals efficiently.

Maintain ethical behavior and professionalism: Adhere to company policies, handle communications diplomatically, and manage stress professionally.

Competency:

• Job Specific Duties: To appropriately and effectively support the function and activities of the Sales Department.
• Job Knowledge & Business Acumen: To maintain broad familiarity with all company and department policies, practices, procedures, product knowledge, industry trends and job tasks to complete critical or complex projects, resolve problems and/or initiate process improvement strategies.
• Communication and Ethics: To appropriately and ethically represent the company and initiate actions and/or communications which will best serve the interests of VQ OrthoCare.

Education/Experience:

High School Diploma/GED

• Associate’s Degree-preferred
• Additional 2 years related experience or equivalent of education plus directly related education, training and experience

QUALIFICATIONS:

• 2 years experience processing orders in a healthcare workplace environment
• 2 years experience conducting insurance verifications
• solid understanding of insurance Explanations of Benefits (EOB's)
• Highly proficient in software such as Word, Excel, PowerPoint and other standard MS Office Programs
• Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, decimals, and percentages

PREFERRED QUALIFICATIONS:

• Preferred Bi-Lingual Spanish

Physical and Mental Demands:

• Typically interacts with staff, peers, senior management and external customers
• Ability to handle moderate to high stress
• Regularly required to sit, stand, move about, stoop, bend, reach, finger and grasp and to move and/or lift up to 20 pounds
• Regularly must see and read computer displays and reports, PDA displays & cell phone displays
• Must regularly type and or enter data using computer keyboards.

Certificates and Licenses:

• No special certificates, licenses or registrations are required

Supervisory Responsibilities:

The job has no supervisory responsibilities.

Work Environment:

Reasonable accommodations may be provided in order to allow qualified individuals with disabilities to perform the essential duties and tasks.

The work environment varies between that of a typical office setting with controlled temperature and humidity and a typical automobile interior, traffic and noise associated with commuting, along with typical patient home environments for short durations. Ambient noise levels are consistent and generally low to moderate.

**VQ OrthoCare is and Equal Opportunity Employer: All Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

***VQ OrthoCare is a participating E-Verify employer