Insurance Specialist (HHC) - 40 hrs - Days -

GENERAL SUMMARY:

Under general supervision, identifies and determines in accordance with established policies and procedures the accuracy and completeness of financial, insurance and/or demographic information for patients receiving care HFHS. Accountable and responsible for all pre-admissions, admissions, and specified scheduled outpatient services rendered at HFHS. Investigates and reviews the accuracy and completeness of insurance information upon pre-admission and/or admission to ensure account is secure prior to discharge. Obtains benefit, co-pay, deductible, and co-insurance information. Verifies insurance eligibility and benefit information and confirms that all insurance requirements are met, including but not limited to referrals and authorizations. Resolves problem accounts to determine primary insurance and/or COB information.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

A variety of functions and responsibilities related to insurance verification and identifying authorization requirements prior to and/or after discharge of patient, which includes:

1. Research and review all insurance plans and confirms patient benefit eligibility, including patient liabilities, clauses, riders, and secondary payor information (coordination of benefits) via internal and external resources including contacting payor representatives as needed.

2. Reviews and interprets insurance group pre-certification requirements. Ensures proper pre-authorizations have been obtained. Executes on-line operations for specific payors to complete the pre-certification process. Communicates data to HFHS Utilization Management Department for further medical review.

3. Resolves discrepancies with the patient and/or family members, employers and insurance companies to assist in obtaining insurance information. Interviews patients and/or family members; advises patient with regards to next steps or processes for securing financial coverage. Reviews and analyzes third party COB screen prior to billing to prevent claims rejection. Works with patient or family member regarding outstanding COB issues.

4. Reviews, analyzes and corrects COB discrepancies and other related issues to ensure the integrity of the insurance information is accurate prior to discharge.

5. Handles insurance questions and/or obtains information from various HFHS areas including but not limited to clinics, physicians, patients, attorneys, employers and outside agencies via telephone or mail.

EDUCATION/EXPERIENCE REQUIRED:

• High school diploma or GED equivalent is required.
• Two (2) years of experience related to healthcare insurance eligibility, insurance verification or insurance billing in a hospital/medical office setting.
• Knowledge of various insurance coverage, COB rules of priority and processing procedures.
• Insurance payor systems experience required.
• EPIC training/experience preferred.
• ICD-10 medical terminology experience preferred.

Additional Information

• Organization: Community Care Services
• Department: HHC Intake
• Shift: Day Job
• Union Code: Not Applicable