Qualification Specialist

AdaptHealth, LLC•Addison Township, IL

18h•$23 - $24•Onsite

About The Position

The Qualification Specialist is responsible for evaluating patient eligibility and medical necessity for Durable Medical Equipment (DME), Positive Airway Pressure (PAP) devices, and oxygen therapy services. This role ensures compliance with insurance requirements, regulatory standards, and clinical guidelines while facilitating timely access to medically necessary equipment for patients.

Requirements

Knowledge of Medicare/Medicaid guidelines, commercial insurance policies, medical necessity criteria, and DME/respiratory equipment coverage requirements with relevant experience
Understanding of Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), HIPAA requirements, and healthcare compliance standards with 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 services.
Strong critical thinking, diligence, problem-solving abilities, and capacity to evaluate complex medical and insurance information accurately and efficiently.
Excellent written and verbal communication skills with professional demeanor for patient interactions and ability to coordinate effectively with healthcare providers and insurance representatives.
Advanced skills in patient management systems, insurance portals, electronic health records, Microsoft Office Suite, and ability to learn new software applications quickly.
High ethical standards, integrity in handling confidential information, patience and empathy when collaborating with patients, and commitment to ensuring appropriate patient access to care.
Ability to work independently with strong organizational skills while collaborating effectively with clinical and operational teams to achieve patient care objectives.
High school diploma or equivalent required
One (1) year of work-related experience

Nice To Haves

Associate’s degree in healthcare administration, Business Administration, or related field preferred
Previous experience in healthcare, insurance, medical billing, or patient services preferred.
Knowledge of respiratory therapy or DME services preferred.
One (1) year of work-related experience plus Two (2) years exact job experience
One (1) year of work-related experience plus Four (4) years exact job experience

Responsibilities

Evaluate patient medical records, physician orders, and clinical documentation to determine eligibility for DME, PAP, and oxygen therapy equipment.
Review diagnostic test results, medical history, and treatment plans to assess medical necessity in accordance with Medicare, Medicaid, and commercial insurance guidelines.
Verify patient insurance benefits, coverage limitations, and prior authorization requirements for prescribed medical equipment.
Submit authorization requests with complete clinical documentation and follow up on pending approvals to ensure timely patient access to equipment.
Analyze physician orders, sleep studies, pulmonary function tests, and other clinical documentation to ensure compliance with coverage criteria.
Identify missing or incomplete documentation and coordinate with healthcare providers to obtain required information.
Ensure all qualification activities comply with Medicare Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), and commercial insurance policies.
Maintain current knowledge of regulatory changes and coverage requirements for respiratory and DME services.
Collaborate with physicians, respiratory therapists, discharge planners, and clinical staff to gather necessary documentation and clinical information.
Provide guidance on documentation requirements and coverage criteria to facilitate appropriate referrals.
Contact patients to gather additional medical information, explain coverage requirements, and communicate qualification decisions.
Provide clear explanations of insurance benefits, coverage limitations, and patient financial responsibilities.
Monitor authorization status, track approval timelines, and manage reauthorization processes for ongoing therapy requirements.
Maintain detailed records of all authorization activities and communication with insurance providers.
Prepare and submit appeals for denied authorizations, including compilation of additional clinical evidence and peer-to-peer review coordination.
Collaborate with clinical teams to develop strong appeals based on medical necessity and coverage criteria.
Conduct internal quality reviews of qualification decisions and documentation to ensure accuracy and compliance.
Support external audits by providing requested documentation and qualification records.
Utilize patient management systems, insurance portals, and electronic health records to process qualifications and maintain accurate records.
Generate reports on qualification metrics, approval rates, and processing times.
Identify opportunities to streamline qualification processes, reduce approval times, and improve patient satisfaction while maintaining compliance with all regulatory requirements.
Maintains patient confidentiality and functions within the guidelines of HIPAA.
Completes assigned compliance training and other education programs as required.
Maintains compliance with AdaptHealth's Compliance Program.
Performs other related duties as assigned.