Insurance Specialist - Case Management - Full Time

IRMC Career•Indiana, PA

10d•Onsite

About The Position

In this role you will be: Verify patient insurance eligibility, benefits, coverage limitations, and authorization requirements prior to or during services. Obtain and manage initial and continued insurance authorizations for inpatient services, including admissions, procedures, and extended stays. Conduct insurance benefit investigations and communicate coverage details, patient responsibility, and financial obligations to patients, families, and hospital staff as appropriate. Review medical documentation to ensure medical necessity and compliance with payer guidelines. Coordinate with clinical staff, case management, utilization review, and physicians to obtain required clinical information for authorizations and appeals. Maintain accurate and timely documentation of insurance verification, authorizations, communications, and payer determinations in the electronic health record and billing systems. Serve as a liaison between the hospital, insurance companies, and patients to resolve coverage issues and payment discrepancies. Stay current on payer policies, reimbursement regulations, and changes in insurance requirements, including Medicare, Medicaid, and commercial plans. Assist with audits and compliance reviews related to insurance authorization and reimbursement. Ensure compliance with hospital policies, federal and state regulations, and HIPAA privacy standards. Perform other related duties as assigned to support revenue cycle operations and patient access services.

Requirements

High school graduate/degree or diploma in a health-related field
Experience with daily insurance portals that require verification process and barriers preferred
Denials/appeals coordination as well as experience with software including, but not limited to, Davinician, Optum, HER, Challenger, Xsolis
Basic computer skills and office equipment experience required

Nice To Haves

Minimum 1 year's clinical experience hospital or related setting preferred

Responsibilities

Verify patient insurance eligibility, benefits, coverage limitations, and authorization requirements prior to or during services.
Obtain and manage initial and continued insurance authorizations for inpatient services, including admissions, procedures, and extended stays.
Conduct insurance benefit investigations and communicate coverage details, patient responsibility, and financial obligations to patients, families, and hospital staff as appropriate.
Review medical documentation to ensure medical necessity and compliance with payer guidelines.
Coordinate with clinical staff, case management, utilization review, and physicians to obtain required clinical information for authorizations and appeals.
Maintain accurate and timely documentation of insurance verification, authorizations, communications, and payer determinations in the electronic health record and billing systems.
Serve as a liaison between the hospital, insurance companies, and patients to resolve coverage issues and payment discrepancies.
Stay current on payer policies, reimbursement regulations, and changes in insurance requirements, including Medicare, Medicaid, and commercial plans.
Assist with audits and compliance reviews related to insurance authorization and reimbursement.
Ensure compliance with hospital policies, federal and state regulations, and HIPAA privacy standards.
Perform other related duties as assigned to support revenue cycle operations and patient access services.