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Insurance Verification Specialist FT On-Site
4 months ago
Minimum Requirements: High School diploma or equivalent required. Minimum 2 years of experience as a hospital verifier or equivalent. Extensive knowledge of Medicare and other government payer rules and regs, and ability to understand and apply Managed Care contract terms.
Essential Job Responsibilities:• Verify eligibility and benefits • Verify effective date. • Change incorrect insurance products (HMO vs. PPO, etc.) which will cause an account to prorate incorrectly. • Follow up on incorrect demographic and insurance information which can impede cash flow and collection efforts. • On WC, verify employer name and address. • Determine if a plan is self-funded or fully-funded to aid in future collection activity and determine whether or not to pursue prompt pay. • Determine if authorizations and referrals are needed and follow up with hospital and physicians’ offices until complete. • Determine if family deductibles apply to patient. • Determine if there are life-time or annual maximum benefits. • Determine maximum out of pocket expense. • Verify coordination of benefits. • Ask if pre-existing condition clause applies, and if so document the details and forward to the hospital. • Determine the patient financial responsibility based on the costs, procedures scheduled and specifics of the individual managed care contracts. • Run reports to determine current average charges for procedures. • Determine if implants will be involved, and if so, how they are covered by the insurance. • Check for inpatient only procedures for Medicare patients on Addendum E. • Check for HASC appropriate procedures on TMHP website for Medicaid. • Determine Medicare coinsurance based on procedures listed in Addendum B. • Do medical necessity checks for Medicare O/P and day surgery procedures based on diagnosis and procedures ordered and notify hospital when those checks fail. • Review physician orders as needed to verify scheduling. • Communicate status conflicts to hospital case management/CDI specialist.• Performs other duties as assigned.
