INSURANCE SPECIALIST I

Patient Care America•Pompano Beach, FL

About The Position

Patient Care America is a premier renal healthcare provider specializing in precision medicine nutrition support and clinical solutions for kidney disease patients. We offer evidence-based therapies such as IDPN (Intradialytic Parenteral Nutrition) and IPN (Intraperitoneal Nutrition) to help manage malnutrition and improve clinical outcomes. Backed by published research demonstrating improvements in albumin levels, our therapies are trusted by nephrology teams and dialysis clinics nationwide. Proudly accredited by PCAB, ACHC, and NABP, we uphold the highest standards of safety, quality, and care. But our commitment extends far beyond delivering infusion therapies; our value-added services include oral nutrition supplement programs, access to our clinical support nurse team, patient support networks and free continuing education for registered dietitians and nurses. As a leading renal solutions provider, we also offer bundled prescription medications, streamlining delivery and supporting improved medication adherence. To support patients beyond the clinic, we provide digital tools and community-based platforms tailored to their needs and experiences. These tools include educational resources, the TransplantLyfe365 app, and an online peer community (www.TransplantLyfe.com [http://www.TransplantLyfe.com]) that helps patients connect with others and manage the everyday challenges of chronic kidney disease and transplantation. Driven by a dedicated commitment to scientific rigor, clinical excellence and compassionate care, Patient Care America is redefining what it means to be a true partner through each stage of kidney care. 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.

Requirements

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 coordinating 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+.
You must be able to pass a drug, background screen and be eligible to work in the U.S.

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 all required documentation is accurate and complete.
Completing submissions promptly
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 Senior 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 on appeal issues
Prepare and submit appeal requests to insurance companies, ensuring all required documentation is complete and accurate.
Other duties as assigned.