Insurance Verification Specialist

The Insurance Verification Specialist plays a critical role in ensuring the financial stability of the federally qualified health center (FQHC) by verifying patient insurance information, ensuring the health center is designated as the primary care provider (PCP), assisting patients with changing their PCP when necessary, obtaining prior authorizations, and ensuring coverage details are accurate and up to date. This position supports the health center's mission to provide accessible, high-quality healthcare to underserved populations.

Key Responsibilities:

1. Insurance Verification:
   • Verify patient insurance coverage prior to appointments, including eligibility, benefits, and network status.
   • Confirm that the health center is listed as the patient’s primary care provider (PCP).
   • Ensure accurate documentation of insurance information in the electronic health record (EHR) system.
   • Communicate with insurance companies to verify coverage details, including co-pays, deductibles, and coinsurance.
2. Authorization and Referrals:
   • Obtain necessary prior authorizations for procedures, medications, and specialist referrals.
   • Track and follow up on pending authorizations to avoid delays in patient care.
   • Coordinate with clinical staff to provide timely updates on authorization statuses.
3. Patient Assistance:
   • Communicate with patients regarding their insurance status and any necessary actions to ensure coverage.
   • Assist patients in the process of changing their PCP to the health center, including providing guidance on contacting their insurance provider.
   •  Educate patients on the importance of having the health center as their designated PCP for continuous and coordinated care.
   • Provide support for patients in resolving insurance-related problems.

1. Documentation and Compliance:

• Maintain accurate and detailed records of insurance verifications, authorizations, and communications in the EHR.
• Ensure all insurance information is updated and accurate in the EHR system.
• Stay informed about changes in insurance policies and procedures, and communicate these changes to relevant staff members.
• Comply with all federal, state, and local regulations, as well as health center policies and procedures.

1. Collaboration:
   • Work closely with the billing and coding teams to resolve discrepancies and denials related to insurance verification.
   • Collaborate with front desk and clinical staff to ensure seamless patient workflow and accurate data entry.
   • Participate in team meetings and contribute to process improvement initiatives.
   • Assist in training and onboarding new staff members as needed.
   • Coordinate with insurance companies to resolve any coverage issues or discrepancies.
   • Maintain effective communication with patients, addressing their concerns and providing updates on insurance verification status.

Qualifications:

• Education: High school diploma or equivalent required; Associate's degree or relevant certification in healthcare administration, medical billing, or a related field preferred.
• Experience: Minimum of 2 years of experience in insurance verification, medical billing, or a similar role in a healthcare setting, preferably in an FQHC or community health center.
• Skills:
  • Proficient in using EHR systems and other healthcare management software.
  • Strong understanding of various insurance plans, including Medicare, Medicaid, and commercial insurances.
  • Excellent communication and interpersonal skills, with the ability to interact effectively with patients, staff, and insurance representatives.
  • Detail-oriented with strong organizational skills and the ability to manage multiple tasks simultaneously.
  • Knowledge of medical terminology, CPT codes, and ICD-10 codes.
  • Ability to work independently and as part of a team.

Work Environment:

• The role involves working in a typical office environment within the health center.

• The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job: The noise level in the work environment is usually mild.  Ability to handle significant stress.

• The position may require occasional overtime or weekend hours depending on the needs of the health center.

Physical Requirements:

• Ability to sit for extended periods while working on a computer.
• Occasional lifting of office supplies and materials up to 20 pounds.

The above information is intended to describe the most important aspects of the job. It is not intended to be construed as an exhaustive list of all responsibilities, duties and skills required in order to perform the work. The health center reserves the right to revise or change job duties and responsibilities as the business need arises. Additionally, this job description is not intended as an employment contract, implied or otherwise, and the Center continues to maintain its status as an at-will employer.