Insurance Verification & Authorization Specialist (on-site) at PedIM Healthcare

Position Summary

The Insurance Verification & Authorization Specialist is responsible for verifying patient insurance coverage, eligibility, and benefits to ensure a seamless billing and authorization process. This role involves securing prior authorizations, obtaining referrals when necessary, and documenting insurance details in the system. The specialist collaborates with various departments to ensure compliance with payer guidelines and maintains accuracy in patient records.

Essential Duties and Responsibilities

• Verify  patient insurance eligibility, benefits, and coverage status with insurance providers.
• Secure prior authorizations and referrals in accordance with payer contract requirements.
• Accurately document patient insurance details, including policy numbers, group numbers, copays, deductibles, and coinsurance, in the Practice Management (PM) system.
• Maintain and update an internal list of insurance carriers requiring authorization.
• Perform account audits to ensure all necessary authorizations are secured.
• Ensure compliance with medical necessity requirements as per Centers for Medicare & Medicaid Services (CMS) standards.
• Identify patients requiring Medicare Advance Beneficiary Notices of Noncoverage (ABNs).
• Assist the Business Office in obtaining retro-authorizations when needed.
• Follow escalation procedures for missing authorizations and proactively  communicate with stakeholders to prevent payment delays.
• Maintain strict patient confidentiality and comply with HIPAA regulations.
• Perform other duties as assigned.

Qualifications and Requirements 

Technical Skills:

• Proficiency in Electronic Health Records (EHR) and Practice Management (PM) systems, including eClinicalWorks (ECW).
• Strong understanding of government and private payer billing regulations.
• Familiarity with healthcare coding systems and clinic operations.

Soft Skills:

• Excellent customer service, organizational, and communication skills.
• Ability to manage multiple tasks, meet deadlines, and work efficiently in a fast-paced environment.
• Strong problem-solving and analytical skills.
• Ability to work independently while collaborating effectively with patients, providers, and insurance companies in a professional and empathetic manner.

Preferred Knowledge & Abilities

• In-depth understanding of insurance verification, contract benefits, and medical terminology.
• Accuracy in data entry while maintaining information integrity.
• Experience with government and third-party payer guidelines (Medicare, Medicaid, managed care, and commercial insurance).
• Ability to train and support colleagues in insurance verification processes.
• Commitment to service excellence and high-quality patient care.

Education:

• High school diploma or equivalent (GED) required.

Experience:

• Minimum of one year of experience in a medical or billing environment.
• Knowledge of medical terminology preferred.

This role requires strong attention to detail, a proactive approach, and the ability to navigate the complexities of insurance verification while ensuring compliance with industry regulations. If you have a passion for patient care and expertise in insurance verification, we encourage you to apply! 

PM20

Compensation details: 16-18 Hourly Wage

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