Insurance Verification Specialist

City of Hope•South Pasadena, CA

11d•Onsite

About The Position

Under the general direction of a supervisor or manager, responsible for performing insurance verification functions and obtaining authorizations from various insurance carriers. This role requires a high level of independent judgement in order to successfully coordinate and obtain proper authorization requests for complex managed care and private insurance patients in a timely and efficient manner. This individual is expected to utilize telecommunications and computer information systems to verify patient data, patients’ treatment planned course, verify insurance, and obtain authorizations. The Insurance Specialist/Auditor is best defined as a highly independent and flexible resource that focuses on system-specific service lines that are in alignment with the patient experience initiative. Furthermore, this role must multi-task between different patients to ensure an extraordinary patient experience and that quality standards are met. Additional duties include, but are not limited to physician, physicist and patient communication serving as an information resource.

Requirements

High School Diploma
Three years related healthcare pre-registration/referral experience required.
Medical terminology and electronic medical record experience required.

Responsibilities

Identifies insurance companies requiring prior authorization for services and obtains authorization.
Coordinates authorizations for procedures and testing requested by providers for the care of their patient.
Reviews charts on inpatients and outpatients and reports to third party payors.
Retrieves radiation oncology orders from chart, and requests authorization through the insurance companies.
Prepares all forms required by third party payor for treatment authorization requests.
Work on all pending utilization review patients, and achieve authorization for the following day(s).
Getting emergent authorizations from emergent patients.
Verifying with the insurance companies and documents what needs to be pre-certified.
Educates patient of their insurance policy.
Composes letters and memoranda from physician dictation, or verbal direction for submission to insurance companies to obtain authorization or appeal denials.
Maintains current records on managed care patients.
Documents in the ARIA and EPIC electronic medical records.
Performs pre-registration functions prior to the patient appointment (including, but not limited to: obtains and/or verifies demographic, clinical, financial, insurance information, service eligibility, consent forms, and patient/guarantor information for pre-registered accounts).
Contacts patients, payers, or other staff members to confirm and verify insurance and demographic information.
Refers patients to financial counselors to resolve insurance or payments issues.
Identifies and resolves issues by working with patients, payors, and/or other CoH departments and personnel in a single interaction with the patient.
Identifies patients with “share of cost” or co-payments by performing pricing estimations, and notifies patients of their expected patient liability and financial responsibility.
Collects patient/guarantor liabilities and refers patients who are uninsured/underinsured to Financial Counselor for charity, financial assistance or governmental program screening and application processes.
Notifies CoH contracting department of patients with a non-contracted insurance to prepare a Letter of Agreement (LOA) should patient to pursue services at COH and informs patient of approval status.
Performs activities required to financial clearance for all patient types.
Frequent communications will occur with patients/family members/guarantors, physicians/office staff, medical center and payors.