Insurance Specialist

WVU Medicine

About The Position

The Insurance Specialist assures that appointments and procedures are authorized. The role contacts insurance carriers to verify coverage and benefit limitations, obtains pre-authorizations for tests and procedures, and calculates deductibles, co-payments, account balances, and fees. The specialist records relevant information in the system for front-end collection and helps minimize reimbursement errors caused by inaccurate referral or enrollment information. The position works with patients, insurers, providers, and hospital or clinic departments to resolve coverage issues, assess medical necessity, document authorization information, anticipate charges, and support financial counseling and denial management. It uses EPIC work queues for scheduling, transition of care, and billing edits.

Requirements

High school diploma or equivalent.
State criminal background check and, if applicable, federal background check as required for regulated areas.
Excellent oral and written communication skills.
Basic knowledge of medical terminology.
Basic knowledge of ICD-10 and CPT coding, third-party payors, and business math.
General knowledge of time-of-service collection procedures.
Excellent customer service skills and telephone etiquette.
Minimum typing speed of 25 words per minute.
Reading and comprehension ability.

Nice To Haves

Previous insurance authorization experience.

Responsibilities

Identify patients requiring pre-certification or pre-authorization when services are requested or when notified by another hospital or clinic department.
Follow up on accounts as indicated by system flags.
Contact insurance companies or employers to determine eligibility and benefits for requested services.
Follow up with patients, insurance companies, or providers to resolve insurance coverage issues and obtain financial resolution.
Use EPIC work queues for scheduling, transition of care, and billing edits.
Perform medical necessity screening as required by third-party payors.
Document referrals and authorization or certification numbers in EPIC.
Initiate charge anticipation calculations and accurately identify anticipated charges, including anticipated self-pay portions.
Communicate anticipated self-pay portions, co-payments, deductibles, co-insurance, and account balances to patients; refer self-pay patients and patients with limited or exhausted benefits to in-house Financial Counselors to determine eligibility.
Assist Patient Financial Services with denial management and appeal denials based on medical necessity as needed.
Communicate workflow-hindering problems to management in a timely manner.
Assess self-pay patients for potential public assistance through registration and billing systems; provide self-pay and under-insured patients with financial counseling information.
Maintain current knowledge of major payor payment provisions.