Lead Insurance Specialist

WVU Medicine•Wheeling, IL

5d•Onsite

About The Position

The Lead Insurance Specialist oversees the daily operations of insurance and registration specialists working on appointments and procedures that require authorization. The role trains staff and keeps them informed about changes in insurance coverage, while updating the manager or supervisor about insurance changes. The specialist ensures appointments and procedures are authorized by verifying coverage and benefit limitations with insurance carriers, obtaining pre-authorizations, and scheduling tests and procedures. They calculate deductibles, co-payments, account balances, and fees, documenting amounts for front-end collection, and help minimize reimbursement errors caused by inaccurate referral or enrollment information. The role also supports insurance verification, medical necessity screening, authorization and referral documentation, charge anticipation, patient financial communications, denial management, and financial counseling referrals. Work is performed in an outpatient clinical environment and involves use of the EPIC system, hospital communications systems, and standard office equipment.

Requirements

High school diploma or equivalent.
Excellent oral and written communication skills.
Basic knowledge of medical terminology.
Basic knowledge of ICD-10 and CPT coding.
Basic knowledge of third-party payors.
Basic knowledge of 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.

Responsibilities

Train new and existing insurance specialists on insurance needs and processes in clinical offices.
Provide ongoing training and share updates and changes to insurance coverage.
Identify patients requiring pre-certification or pre-authorization when services are requested or when notified by another 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, insurers, or providers to resolve insurance coverage issues.
Use EPIC work queues for scheduling, transition of care, and billing edits.
Perform medical necessity screening as required by third-party payors.
Document referral, authorization, and certification numbers in EPIC.
Initiate charge anticipation calculations and identify anticipated charges and self-pay portions accurately.
Communicate anticipated self-pay amounts, co-payments, deductibles, co-insurance, and account balances to patients; refer eligible self-pay patients or patients with limited or exhausted benefits to in-house Financial Counselors.
Maintain current knowledge of major payor payment provisions and regulations.
Assist Patient Financial Services with denial management and appeal denials based on medical necessity as needed.
Use applicable computer software and equipment for access processing and follow established computer downtime procedures.
Participate in educational programs addressing mandatory requirements and job or personal growth needs.
Follow established work systems, identify and communicate deviations or deficiencies to a supervisor or manager.
Maintain confidentiality when communicating demographic, clinical, and financial information.
Communicate politely and respectfully with staff, physicians, patients, families, and the public.
Use hospital communications systems and equipment in accordance with hospital standards.
Communicate workflow problems to management in a timely manner.
Assess self-pay patients for potential public assistance through registration and billing systems and provide financial counseling information to self-pay or under-insured patients.