Insurance Specialist III

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This position is responsible for obtaining authorizations for elective infusions and injections to financially clear patients and ensure reimbursement for the organization. Payor resources and any other applicable reference material such as payor and medical policies should be utilized to verify accurate prior authorization requirements. Escalates financial clearance risks as appropriate in compliance with the Financial Clearance Program. Serving as a liaison between clinical teams and pharmacists ensuring effective communication regarding infusion prior authorization issues. Cases are to be coded, and clinical documentation reviewed to ensure the documentation is complete to maximize reimbursement.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. High school graduate or equivalent with 2 years working experience in a medical environment,

(such as a hospital, doctor’s office, or ambulatory clinic.)

OR

2. Associate’s degree and 1 year of experience in a medical environment.

PREFERRED QUALIFICATIONS:

EXPERIENCE:

1. 3 years’ experience of knowledge and interpretation of medical terminology, ICD-10, and CPT codes.

2. Understanding of authorization processes, insurance guidelines, and third-party payors practices.

3. Proficiency in Microsoft Office applications.

4. Excellent communication and interpersonal skills.

5. Ability to prioritize to meet deadlines and multitask a large work volume with a high level of efficiency and attention to detail.

6. Basic computer skills.

CORE DUTIES AND RESPONSIBILITIES: As an advocate for WVUH/UHA employees, company and departmental goals and initiatives and HR Compliance, demonstrate knowledge of management and employee needs and apply that knowledge to create solutions.

1. Utilize work queues within the EPIC system to manage workloads and prioritize to meet

deadlines.

2. Collect and communicate outpatient benefit information to the Patient Financial Services team

via queues and billing indicators in Epic.

3. Refer to medical and coverage policies for medications.

4. Research CPT codes for drugs/injections.

5. Verify authorization requirements by utilizing insurance portals or calling insurances.

6. Submit authorizations as a buy-and-bill via medical benefit for outpatient on-campus hospital

requests by utilizing insurance portals, prior authorization forms, or calling insurances.

7. Review and interpret medical record documentation to answer clinical questions during the

authorization process.

8. Clearly and effectively communicate with clinics when additional information is needed.

9. Uses hospital communications systems (fax, pagers, telephones, copiers, scanners, and

computers) in accordance with hospital standards.

10. Daily follow up on submitted authorization requests.

11. Scheduling and following up on peer to peers.

12. Submitting and following up with prior authorization appeals for denied medications.

13. Clearly and effectively communicate to the appropriate persons when home infusion or

pharmacy benefit is needed.

14. Verification of referrals and authorizations in work queues.

15. Identify changes in medication dosing/frequency.

16. Assists Patient Financial Services with denial management issues and will obtain retro authorizations as needed.

17. Maintain in baskets in Epic and emails in Outlook.

18. Participate in monthly team meetings and one-on-ones.

19. Builds admissions and submit authorization for elective inpatient chemotherapy admission and

observations.

20. Follows established workflows, identifies deviations or deficiencies in

standards/systems/processes and communicates problems to supervisor or manager.

21. Is polite and respectful when communicating with staff, physicians, patients, and families.

Approaches interpersonal relations in a positive manner.

22. Maintains confidentiality according to policy when interacting with patients, physicians,

families, co-workers, and the public regarding demographic/clinical/financial information.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Prolonged periods of sitting.

2. Extended periods on the telephone requiring clarity of hearing and speaking.

3. Manual dexterity required to operate standard office equipment.

4. Must have manual dexterity to operate keyboards, fax machines, telephones, and other business

equipment.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Outpatient clinical environment.

SKILLS AND ABILITIES:

1. Excellent oral and written communication skills.

2. Basic knowledge of medical terminology.

3. Basic knowledge of ICD-10 and CPT coding.

4. Basic knowledge of third-party payors.

5. Basic knowledge of business math.

6. General knowledge of time-of-service collection procedures.

7. Excellent customer service and telephone etiquette.

8. Minimum typing speed of 25 works per minute.

9. Must have reading and comprehension ability.

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Non-Exempt)

Company:

SYSTEM West Virginia University Health System

Cost Center:

536 SYSTEM Hospital Authorization Unit