Insurance Verification Specialist I

3 weeks ago

Niles, United States Edward-Elmhurst Health Full time

Position Highlights:

- Position: Insurance Verification Specialist
- Location: Niles, IL
- Full Time
- Hours: Monday-Friday, standard business hours

A Brief Overview:
Under the management of the Manager, Patient Access, the Pre-Certification Representative I is responsible to determine insurance eligibility and, as appropriate benefits, pre-authorization / pre-certification and medical necessity requirements based on patient specific insurance. The Pre-Certification Representative I provides this service to ensure that our customers are provided a high quality experience which includes understanding of patient responsibility and ease of access to clinical services. This is achieved through coordination with and education of the patient. The Pre-Certification Representative I helps to insure that patient satisfaction and loyalty are achieved while hospital and Medical Group revenue is optimimized.

What you will do:

- Use NorthShore protocol to verify patient selection
- Performs online eligibility and benefit checks for applicable payers as outlined in guidelines.
- Enters data accurately into Epic in accordance with standards.
- Calls the insurance company directly to obtain required eligibility and benefit information for all managed care, governmental and commercial payers,
- Verifies if pre-certification is required.
- Process accounts according to performance standards - timing, volume and quality
- Use NorthShore protocol to verify patient selection
- Utilize established protocols to register patient (e.g. select insurance and guarantor, verify/enter demographic information)
- Provide instructions to patient (e.g. prep instructions related to procedure, location, co-pay)
- Accesses Medicare LMRP software to determine if ABN (Advance Beneficiary Notice) is required.
- Ascertain medical necessity requirements for visit utilizing NEBO Eligibility Software.
- If medical necessity check fails, contact physician for more appropriate diagnosis if available.
- Generate and complete ABN when needed and contacted the ordering physician and patient as outlined in procedural guidelines to communicate and explain requirement.
- For pre-registered patients, fax the ABN to the responsible check-in area (department or registration) for the service
- Document all activities in Epic appropriately.
- Process accounts according to performance standards - timing, volume and quality
- Contacts physician office or insurance company to check status of and / or obtain existing precertification number for ordered service.
- Documents obtained information including certification number and number of days approved for inpatients into Epic.
- If authorization is not obtained as required, contact physician office and department regarding cancellation of procedure.
- If authorization is not obtained due to medical necessity, contact ordering physician's office and patient regarding waiver requirement.
- Generate and forward waiver as needed to department for patient signature
- Follows standards for documenting cases and forwarding to Financial Counseling.
- Identify if callers have an existing NorthShorConnect account
- If not, introduce NorthShoreConnect and encourage patient use
- Utilize Epic to create NorthShoreConnect account for patients
- Follow all NorthShore protocols to ensure compliance with HIPAA

What you will need:

- High School Required
- 1 year of experience in a contact center, healthcare environment or customer service role.
- Experience with referrals and pre-certification strongly preferred.
- Strong attention to detail to accurately enter data and research and resolve questions
- Ability to recognize customers' anger and attempt to defuse it
- Knowledge of medical terminology and health insurance terminology, preferred
- Front desk/central scheduling and/or registration experience, preferred
- Epic experience, preferred

**Benefits**:

- Career Pathways to Promote Professional Growth and Development
- Various Medical, Dental, and Vision options, including Domestic Partner Coverage
- Tuition Reimbursement
- Free Parking at designated locations
- Wellness Program Savings Plan
- Health Savings Account Options
- Retirement Options with Company Match
- Paid Time Off and Holiday Pay
- Community Involvement Opportunities

Endeavor Health is a fully integrated healthcare delivery system committed to providing access to quality, vibrant, community-connected care, serving an area of more than 4.2 million residents across six northeast Illinois counties. Our more than 25,000 team members and more than 6,000 physicians aim to deliver transformative patient experiences and expert care close to home across more than 300 ambulatory locations and eight acute care hospitals - Edward (Naperville), Elmhurst, Evanston, Glenbrook (Glenview), Highland Park, Northwest Community (Arlington Heights) Skokie and Swedish (Chicago) - all recognized as Magnet hospitals for nursing excellence. For more information, visit


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