The Insurance Verification (IV) Specialist is responsible for insurance and benefit verification processing for radiation oncology, Infusion, genetics and research, and all other services as assigned. Works directly with patients, internal and external business partners (I.e. IPAs and insurance companies), and clinical departments for delivery of services to include but is not limited to: verification of insurance benefit and coverage, explanation of clinical documentation to support proper authorization and level of service, obtaining authorizations for services, and for accuracy of benefit data to ensure timely reimbursement of services. Has expert knowledge and understanding of authorization processes. The ability to interpret patient benefits to include deductibles, copayments, and coinsurance. Has knowledge of CPT and ICD10/Procedure Codes, Medical policies, LCD’s and Medical terminology. Works efficiently to ensure documentation and notification is processed in a timely manner. Maintains accurate charge entry and reconciles daily charges. Strives within a team atmosphere has strong customer service expertise, has the ability to multi-task, and proficient computer skills.
- Verify insurance coverage for all assigned patients.
- Ensure the procedure is covered under the patient’s plan and guidelines.
- Reviews physician orders for Medical Necessity
- Obtains Authorizations for treatment in Infusion or Radiation Oncology
- Arrange for peer-to-peer evaluations between physician offices and insurance companies as requested.
- Provide patient education of service benefits, the status of pending or denied authorizations and limited benefit coverage. Seeks assistance to maintain the service level and to avoid delays in inpatient care.
- Avoids cancellation of service at all costs.
- Enter daily charges for each specialty: either Radiation Oncology or Infusion.
- Apply excellent communication and teamwork skills to maintain successful working relationships with team members and various groups throughout the organization.
- Listen effectively. Build appropriate rapport. Use diplomacy and tact.
Education, Training, and Experience:
- High School diploma or equivalent with 2-3 years of patient access or related healthcare experience.
- Background in billing, insurance verification, coding, patient access or appointment scheduling.
- Degree and/or certificates in a related field.
Skills or Other Qualifications:
- Self-directed individual with the ability to prioritize tasks and meet deadlines, excellent attention to detail, and maintain a high level of work quality.
- A strong team player with excellent oral, verbal and presentation communication skills.
- Proven ability to interface with all customer levels (physicians, Organizational staff, insurance companies, patients and family members).
- Working knowledge of Microsoft Office Suite, including Outlook, Word, Excel, and PowerPoint, plus healthcare database systems.
- Decisive and capable of exercising good judgment under pressure.
- Possesses thorough knowledge of insurance verification and authorization guidelines for outpatient infusion, Radiation Oncology, and Genetics; including insurance requirements and guidelines, ICD-10 and CPT 4 coding.
- Knowledge and understanding of benefit plans, plan and coverage, and claims responsibility.
- Strong grasp on medical terminology with an emphasis in Oncology.