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Insurance Verification/Referral Specialist
3 weeks ago
The Insurance Verification/Referral Specialist ensures timely and accurate patient care by verifying insurance coverage and obtaining required referrals prior to services being rendered. This role demands a strong understanding of insurance processes and effective communication skills to inform patients of their financial responsibilities and address any eligibility concerns. The specialist works closely with patients, insurance payers, and internal departments-including Chemotherapy Services, Patient Access, Revenue Cycle, and clinical teams-to facilitate a smooth and compliant registration and treatment process.
CORE ESSENTIAL RESPONSIBILITIES:
- Verify insurance coverage and benefits for new and established patients using real-time eligibility (RTE), insurance portals, or phone, and ensure timely updates to the Practice Management system.
- Review registration details using the "Sidebar" checklist to confirm active insurance, patient, and guarantor status, and proper filing order for all coverages.
- Communicate eligibility issues and financial responsibilities (co-pays, co-insurance, deductibles) to patients, and answer insurance-related inquiries.
- Enter patient financial responsibility details into the payment collection or message field to inform the Patient Access Team.
- Evaluate and enter pre-payment amounts for patients receiving treatment; serve as back-up to the Patient Financial Counselor during absences.
- Initiate and obtain insurance referrals for services such as office visits, labs, phlebotomy, and port flushes; coordinate with providers and payers to resolve referral issues and ensure timely approvals.
- Maintain accurate records of all referral requests, approvals, and denials for audit and compliance purposes.
- Respond promptly to inquiries from Patient Access, Patient Services, Chemotherapy Services, and Revenue Cycle teams regarding insurance or referral matters.
- Notify Chemotherapy Services of any coverage issues that could delay treatment or impact the plan of care.
- Support AR specialists with insurance/referral denials and collaborate with Oncology Strategy and Compliance teams as needed; perform other duties as assigned.
EDUCATION & EXPERIENCE:
- High school diploma or equivalent required; associate's degree in healthcare administration, business, or related field preferred.
- Minimum of 2-3 years of experience in insurance verification and referrals with patient interaction.
- Experience with electronic medical records, practice management systems, and insurance portals required. EPIC experience preferred.
- Strong understanding of insurance plans, referral processes, and coordination of benefit.
- Knowledge of medical terminology, CPT/ICD-10 coding, and healthcare billing practices
- Familiarity with HIPAA regulations and patient privacy standards in a clinical or administrative setting
