Insurance Specialist

3 weeks ago

Duarte, United States City of Hope Full time

Join the transformative team at City of Hope, where we're changing lives and making a real difference in the fight against cancer, diabetes, and other life-threatening illnesses. City of Hope’s growing national system includes its Los Angeles campus, a network of clinical care locations across Southern California, a new cancer center in Orange County, California, and treatment facilities in Atlanta, Chicago and Phoenix. Our dedicated and compassionate employees are driven by a common mission: To deliver the cures of tomorrow to the people who need them today. 

This role is essential in the success of supporting clinical trials, the primary task is to verify insurance policy benefit information and obtain authorizations/pre-certifications for services not covered by the clinical trial study. The Research Insurance Specialist will verify with the clinical trial patient’s insurance provider if the incumbent has coverage to participate in the proposed trial, if approved then using a clinical trial study coverage analysis, the research insurance specials will determine for each upcoming appointment whether or not the upcoming service will be covered by the study sponsor or whether the service needs prior authorization to be covered by the patient’s insurance. The Research Insurance Specialist is responsible for obtaining timely authorizations/pre-certifications when needed for all services not covered under the study.

As a successful candidate, you will: 

Obtain Insurance Benefits Confirmation

  • Review billing grid/budget and compile list of all standard of care procedures associated to research
  • Verifies hospital and professional insurance policy benefits for clinical trial patients. The verification process includes: Telephone contact, Mail/Facsimile, On-line inquiry
  • Enters information concerning the policy benefits into the system and updates insurance information in the system.
  • Works in coordination with the research nurses, case managers, financial counselors, to obtain treatment authorizations and pre-certifications through the insurance company and/or the primary care physician.
  • Works with referral, financial support services, admitting, registration and clinics personnel to develop sound financial arrangements.
  • Identifies opportunities for improvement in customer service or insurance company interactions

Ongoing Authorization

  • Review billing grid/budget to determine if upcoming services require authorization and update in medical record.
  • Request authorization extension or new authorizations for continuity of care for research as needed or when coverage changes and inputs updates into the system.
  • Receives and reads City of Hope managed care contracts summaries to obtain an understanding of the contract provisions and interprets for insurance coverage.  Acts as resource regarding managed care contract changes and updates.
  • Investigates and/or ensures that questions and requests for information are responded to in a timely and professional manner to ensure resolution of outstanding accounts.
  • Refers issues to supervisors or other staff for review of denials.
  • Assist case managers, UR nurses, etc., in appealing denials.
  • Participates in meetings with insurance carrier representatives.

Customer Service

  • Ensure a high level of customer service by resource to patients and team members. Serve as a liaison between patients and support staff. Develop effective relationships with colleague, physicians, providers, leaders and other employees across the organization. Demonstrates genuine interest in helping our patients, providers and other employees by using excellent communication skills, being polite, friendly, patient and calm under pressure.
  • Managing multiple, changing priorities in an effective and organized manger, under stressful demand while maintaining exceptional service. Maintain composure when dealing with difficult situations and responding professionally. Independently recognize a high priority situation, taking appropriate and immediate action. Effectively communicates with service delivery and other departments to resolve issues that impact patient care and escalating issues that cannot be resolved in accordance with departmental guidelines.

Quality Assurance

  • Maintains appropriate level of productivity and accuracy for work performed based on department standards. Maintains thorough knowledge of policies, procedures, and standard work within the department in order to successfully performance duties on a day-to-day basis.

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