Qualification Specialist

AdaptHealth, LLC•Addison Township, IL

2h•$21 - $23

About The Position

The Qualification Specialist evaluates patient eligibility and medical necessity for Durable Medical Equipment (DME), Positive Airway Pressure (PAP) devices, and oxygen therapy services. The role ensures compliance with insurance requirements, regulatory standards, and clinical guidelines while helping patients access medically necessary equipment in a timely manner. The lead specialist serves as a subject matter expert and conducts new-hire training and team mentoring. The specialist reviews patient records, physician orders, diagnostic results, and clinical documentation; verifies insurance benefits and authorization requirements; submits and tracks authorization requests; and coordinates with healthcare providers to obtain required information. The role also communicates coverage requirements and decisions to patients, manages reauthorizations and appeals, supports quality reviews and audits, and uses patient management systems, insurance portals, and electronic health records to maintain records and report qualification metrics. The position requires compliance with Medicare and commercial coverage criteria, HIPAA, and AdaptHealth’s Compliance Program. It also involves identifying process improvements, completing assigned compliance training and education, and performing other related duties as assigned. Work is in a professional office setting and includes extended computer work, sustained concentration, and occasional extended hours during peak periods or urgent patient needs.

Requirements

High school diploma or equivalent required.
One year of work-related experience for Specialist Level (Entry Level).
Senior Level requires one year of work-related experience plus two years of exact job experience.
Lead Level requires one year of work-related experience plus four years of exact job experience.
Knowledge of Medicare and Medicaid guidelines, commercial insurance policies, medical necessity criteria, and DME and respiratory equipment coverage requirements.
Understanding of LCDs, NCDs, HIPAA requirements, and healthcare compliance standards, including the ability to interpret complex coverage policies.
Familiarity with respiratory conditions, sleep disorders, medical terminology, diagnostic procedures, and treatment protocols related to DME and oxygen therapy.
Strong critical thinking, diligence, problem-solving, and analytical skills to evaluate medical and insurance information accurately and efficiently.
Excellent written and verbal communication skills for patient interactions and coordination with healthcare providers and insurance representatives.
Advanced proficiency with patient management systems, insurance portals, electronic health records, and Microsoft Office Suite, and ability to learn new software quickly.
High ethical standards and integrity when handling confidential information; patience, empathy, and commitment to appropriate patient access to care.
Ability to work independently with strong organizational skills and collaborate effectively with clinical and operational teams.
Ability to work independently with minimal supervision and flexibility for occasional extended hours during peak qualification periods or urgent patient needs.
Ability to use computers, office equipment, telecommunications systems, and healthcare software applications.
Ability to sustain concentration and handle confidential patient and clinical information with discretion.
Professional verbal and written communication skills for patient interactions and coordination with healthcare providers at all organizational levels.

Nice To Haves

Associate’s degree in healthcare administration, Business Administration, or a related field.
Previous experience in healthcare, insurance, medical billing, or patient services.
Knowledge of respiratory therapy or DME services.

Responsibilities

Evaluate medical records, physician orders, diagnostic test results, medical histories, and treatment plans to determine eligibility and medical necessity for DME, PAP devices, and oxygen therapy.
Verify insurance benefits, coverage limitations, and prior authorization requirements; submit authorization requests with clinical documentation and follow up on pending approvals.
Review clinical documentation for compliance with coverage criteria and coordinate with healthcare providers to obtain missing or incomplete information.
Ensure qualification activities comply with Medicare LCDs and NCDs, commercial insurance policies, and applicable regulatory requirements; maintain current knowledge of changes.
Collaborate with physicians, respiratory therapists, discharge planners, and clinical staff to gather documentation and explain documentation requirements and coverage criteria.
Contact patients to gather information, explain coverage requirements and insurance benefits, communicate qualification decisions, and discuss coverage limitations and financial responsibilities.
Track authorization status and timelines, manage reauthorizations, and maintain detailed records of authorization activities and insurance communications.
Prepare and submit appeals for denied authorizations, compile clinical evidence, and coordinate peer-to-peer reviews with clinical teams.
Conduct internal quality reviews of qualification decisions and documentation, and support external audits by providing requested records.
Use patient management systems, insurance portals, electronic health records, and other healthcare software to process qualifications, maintain records, and generate reports.
Identify opportunities to streamline qualification processes, reduce approval times, and improve patient satisfaction while maintaining compliance.
Maintain patient confidentiality and comply with HIPAA and AdaptHealth’s Compliance Program.
Complete assigned compliance training and other education programs; perform other related duties as assigned.
As a lead specialist, serve as a subject matter expert and conduct new-hire training and team mentoring.