Insurance Specialist

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This position is responsible for obtaining authorizations for elective procedures, services, and tests to financially clear patients prior to services are rendered. Payor resources and any other applicable reference material such as payor and medical policies should be utilized to verify accurate prior authorization requirements. Cases are to be coded, and clinical documentation reviewed to ensure the documentation is complete. Escalates financial clearance risks as appropriate in compliance with the Financial Clearance Program. This role is key to securing reimbursement and minimizing organizational write offs, while supporting the goals of keeping surgery room and schedules at optimal levels.

MINIMUM QUALIFICATIONS:

EDUCATION AND EXPERIENCE

1. High school graduate or equivalent with 2 years working experience in a medical environment, (such as a hospital, doctor’s office, or ambulatory clinic.)

OR

2. Associate’s degree and 1 year of experience in a medical environment required.

PREFERRED QUALIFICATIONS:

EDUCATION AND EXPERIENCE

1. 3 years’ experience of knowledge and interpretation of medical terminology, ICD-10, and CPT codes.

2. Understanding of authorization processes, insurance guidelines, and third-party payors
3. Proficiency in Microsoft Office applications.

4. Excellent communication and interpersonal skills.

5. Ability to prioritize to meet deadlines and multitask a large work volume with a high level of efficiency and attention to detail.

6. Basic computer skills.

CORE DUTIES AND RESPONSIBILITIES: As an advocate for WVUH/UHA employees, company and departmental goals and initiatives and HR Compliance, demonstrate knowledge of management and employee needs and apply that knowledge to create solutions.

1.  Identifies all patients requiring pre-certification or pre-authorization at the time services are requested or when notified by another hospital or clinic department.

2. Contacts insurance company or employer to determine eligibility and benefits for requested services.

3. Use work queues within the EPIC system for obtaining authorization for referrals, tests, and surgeries within expected timeframes.

4. Follows up on submitted authorization requests timely.

5. Ensures accurate coding of the diagnosis, procedure, and facility align with authorization obtained.

6.  Provides authorization verification of services timely to avoid unnecessary delays in treatment and reduce excessive nonclinical administrative time required of providers.

7. Utilize payor resources and any other applicable reference material such as payor and medical policies to verify accurate prior authorization.

8. Review and interpret medical record documentation to answer clinical questions during the

authorization process.

9. Scheduling and following up on peer to peers and denials.

Submitting and following up with prior authorization appeals for denied surgeries.

10. Assists Patient Financial Services with denial management issues and will obtain retro-authorizations as needed.

11. Notifies scheduling and physicians of any cases not authorized within department policy.

12. Excellent time management and organization with time sensitive work.

13. Maintains compliance with departmental quality standards and productivity measures.

14. Works collaboratively and politely with internal and external contacts specifically Physicians, Financial Clearance/Counselor, Schedulers, and Nurses.

15. Uses hospital communications systems (fax, pagers, telephones, copiers, scanners, and computers) in accordance with hospital standards.

16. Maintain in baskets in Epic and emails in Outlook.

17. Participate in monthly team meetings and one-on-ones.

18. Follows established workflows, identifies deviations or deficiencies in standards/systems/processes and communicates problems to supervisor or manager.

19. Is polite and respectful when communicating with staff, physicians, patients, and families.

Approaches interpersonal relations in a positive manner.

20. Maintains confidentiality according to policy when interacting with patients, physicians, families, co-workers, and the public regarding demographic/clinical/financial information.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Prolonged periods of sitting.

2. Extended periods on the telephone requiring clarity of hearing and speaking.

3. Manual dexterity required to operate standard office equipment.

4. Must have manual dexterity to operate keyboards, fax machines, telephones, and other business equipment.

SKILLS AND ABILITIES:

1. Excellent oral and written communication skills.

2. Practical knowledge of medical terminology.

3. Practical knowledge of ICD-10 and CPT coding.

4. Practical knowledge of third-party payors.

5. General knowledge of time-of-service collection procedures.

6. Basic knowledge of business math.

7. Excellent customer service and telephone etiquette.

8. Minimum typing speed of 25 words per minute.

9. Excellent reading and comprehension ability.

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Non-Exempt)

Company:

SYSTEM West Virginia University Health System

Cost Center:

536 SYSTEM Hospital Authorization Unit