Insurance Verification Specialist

December 10

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Boston Medical Center (BMC)

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5001 - 10000 employees

Founded 1996

Description

• The Insurance Verification Specialist role is part of the Revenue Cycle Patient Access team and is responsible for coordinating all financial clearance activities by navigating all referral, precertification, and/or authorization requirements as outlined in payer-specific guidelines and regulations. • The role plays an important dual role by helping to coordinate patient access to care while maximizing BMC hospital reimbursement. • Monitors accounts routed to precertification and prior authorization work queues and clears work queues by obtaining all payer specific financial clearance requirements in accordance with established management guidelines. • Maintains knowledge of and complies with insurance companies’ requirements for obtaining pre-certifications/prior authorizations/referrals, and completes other activities to facilitate all aspects of financial clearance. • Acts as subject matter experts in navigating both the BMC Community and the payer world to get the right “permissions” (authorizations, pre-certs, referrals, for example) for the care plan to proceed. • Uses appropriate strategies to underscore the most efficient process to obtaining authorizations, including on line databases, electronic correspondence, faxes, and phone calls. • Obtains and clearly documents all pre-certifications/prior authorizations for scheduled services prior to admission within the Epic environment. • Collaborates with patients, providers, and departments to obtain all necessary information and payer permissions prior to patients’ scheduled services. • Communicates with patients, providers, and other departments such as Utilization Review to resolve any issues or problems with obtaining required pre-certifications/prior authorizations. • Escalates emergent and elective accounts that have been denied or will not be financially cleared within 3 days of admission as outlined by department policy. • Keeps current on CMS requirements and guidelines. • Coordinates with patients and Patient Financial Counseling to initiate/process Charity Care applications as needed.

Requirements

• High School Diploma or Equivalent required, Associates degree or higher preferred. • Case manager and/or coding certification desirable • 4-5 years medical billing/denials/coding/and/or inpatient admitting experience desirable • General knowledge of healthcare terminology and CPT-ICD10 codes. • Complete understanding of insurance is preferred. • Requires excellent verbal communication skills and the ability to work in a complex environment with varying points of view. • Must be comfortable with ambiguity, exhibit good decision making and judgment capabilities, attention to detail. • Knowledge of and experience within Epic is preferred. • Demonstrates technical proficiency within assigned Epic work queues and applicable ancillary systems, including but not limited to: ADT/Prelude/Grand Central, HB & PB Resolute. • Demonstrates proficiency in Microsoft Suite applications, specifically Excel, Word, and Outlook. • Displays a thorough knowledge of various sections within the work unit in order to provide assistance and back-up coverage as directed. • Displays a deep understanding of Revenue Cycle processes and applies knowledge to meet and maintain productivity standards.