Continued Qualifications Specialist

TEKsystems•Whitpain Township, PA

23h•Onsite

About The Position

The Continued Qualifications Specialist is responsible for obtaining and maintaining all required documentation needed by insurance providers to support the continued, qualified, and authorized use of Durable Medical Equipment (DME) products. This role is critical to ensuring uninterrupted therapy for patients, accurate and timely billing, and compliance with payer requirements. The ideal candidate has strong communication skills, a solid understanding of insurance policies and reauthorization processes, and the ability to collaborate effectively with patients, healthcare providers, payers, and internal teams.

Requirements

Experience in insurance verification, reauthorization, or related healthcare administrative role
Comprehensive knowledge of commercial insurance plans, Medicare, and payer guidelines
Knowledge of medical terminology related to billing and insurance
Ability to perform basic math calculations
Strong written and verbal communication skills with attention to grammar, clarity, and professionalism
Ability to organize work, manage priorities, and meet deadlines
High attention to detail with the ability to work independently with minimal supervision
Strong collaboration skills and ability to build positive working relationships with internal and external stakeholders

Responsibilities

Develop a strong understanding of products, including their application and benefits to patient healing in the home
Conduct routine and scheduled outreach with patients to confirm active therapy use, insurance coverage, and healthcare provider status
Communicate regularly with healthcare providers to obtain payer-required documentation for continued therapy
Coordinate with internal teams to ensure timely product transitions based on insurance eligibility and coverage guidelines
Maintain accurate, real-time documentation of patient demographics, insurance details, authorizations, coverage, assessments, and communication history in digital systems
Assess patient eligibility for specific therapies based on insurance clinical, compliance, and contract guidelines
Complete timely insurance reauthorizations to support continued therapy in the home
Proactively escalate cases that may delay claim submission or result in unbilled claims
Investigate and resolve insurance-related issues, including denied reauthorizations and payer delays
Collaborate with the billing team to ensure accurate and timely claim submissions in compliance with payer requirements
Adhere to federal and state regulations, insurance policies, HIPAA, Medicare, and company compliance standards
Identify opportunities for process improvement and contribute to increased efficiency and effectiveness