Lead Medical Benefits Verification Specialist

Onco360•Waltham, MA

3d•$29•Onsite

About The Position

The Lead Medical Benefits Verification Specialist is responsible to support the Medical Benefits Verification Specialist roles while performing insurance authorization and verification for all patients scheduled for services. The Lead will investigate, review, and load accurate patient insurance for medical coverage, assign coordination of benefits, and investigate/identify authorization requirements needed to obtain medication coverage. Support the department's Manager with the daily workflow and distribution of workload, answer questions as the assigned subject matter experts, assist with mentoring and training new members of the team and report any system or process issues identified.

Requirements

High School Diploma or GED.
3+ years’ Medicare and Medical benefit verification experience
Medicare and Medical insurance and benefit verification, medical contracts, knowledge/understanding of Medicare, Medicaid, and commercial insurance, coordination of benefits, Understanding Medicare Parts A, B, C, and D, as well as relevant laws and guidelines, NDC medication billing, pharmacy or healthcare-related knowledge, knowledge of pharmacy terminology including sig codes, basic math and analytical skills, Intermediate typing/keyboarding skills.
Independent worker, self-motivated
Analytical skills: The ability to interpret complex insurance documents and identify potential gaps in coverage is crucial for handling more difficult cases.
Communication: Excellent verbal and written communication skills are essential for interacting with insurance companies, patients, and other healthcare professionals.
Problem-solving: Senior specialists must possess strong problem-solving skills to efficiently address and resolve insurance-related issues.
Technical proficiency: Expertise in electronic health record (EHR) systems, insurance verification software, and payer portals is necessary.
Leadership abilities: The capacity to mentor junior staff and lead process improvement projects is a key differentiator for a senior role.

Nice To Haves

Associate degree or equivalent program from a 2-year program or technical school, Certified Pharmacy Technician (PTCB), Specialty pharmacy experience
5+ years Specialty Pharmacy, Medical Verification, and/or Infusion benefit verification experience
Specialty Pharmacy experience, Medicare Billing Experience, Medical Authorization experience
Registration with Board of Pharmacy as required by state law or Certified Pharmacy Technician (PTCB) Certified Revenue Cycle Representative (CRCR) Certified Medical Insurance Specialist (CMIS)

Responsibilities

Support staff in verifying Commercial and Government payer eligibility and benefits utilizing electronic resources to load primary, secondary, tertiary, etc. insurances to patient profile. This involves contacting Medicare or other relevant government payers to confirm coverage and benefits for specific services.
Verify Commercial insurance plans eligibility and benefits utilizing electronic resources to load primary, secondary, tertiary, etc. insurances to patient profiles. Confirming patient eligibility and benefits with various commercial insurance carriers (i.e. Aetna, Humana, Anthem, Cigna, etc.).
Facilitate process for requesting medical authorizations, Single Case Agreements, Letter of Agreements, and Terms of Agreement for applicable commercial, Medicaid, and Medicare, or facility medication claims.
Investigate payer plans: Research and document benefit plan specifics for various payer plans, including cost-share responsibilities and restrictions.
Address intricate benefit verification issues, such as those involving high-cost or specialized treatments, denials, and appeals.
Develop expertise: Maintain in-depth knowledge of insurance policies, coverage terms, and complex billing practices.
Identify the appropriate clinical records and submit the authorization request to the insurance company based on plan requirements for approval.
Handle complex cases: Address intricate benefit verification issues, such as those involving high-cost or specialized treatments, denials, and appeals.
Collaborate across departments: Work closely with clinical staff, billing and coding teams, and administrative teams to resolve insurance issues and ensure seamless patient care. Will be the liaison between the ordering physician and insurance company to ensure all requirements to secure approval are identified and communicated.
Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards.
Lead process improvement: Analyze workflows, identify opportunities for improvement, and implement more efficient procedures to reduce turnaround times and improve accuracy.
Assist the Medical Verification Specialists in achieving: >95% accuracy/quality while handling accounts, as measured by account audits >95% quality of expected customer service etiquette, as measured by phone call audits Meet or exceed Lower controls of average productivity amongst the team productivity standards assist the manager of the department with escalated issues, tracking system and process issues.
Mentor and train staff: Guide and train junior specialists on proper benefit verification and claim processing procedures.
Ensure compliance: Adhere to all federal and state regulations, including the Health Insurance Portability and Accountability Act (HIPAA), to maintain patient confidentiality.
Performs other duties as assigned.