Eligibility Enrollment Specialist

Job Summary

The Insurance Verification Specialist III position is responsible for reviewing clinical documentation per HCPCS, CPT, and ICD-10 codes, verifying benefits and eligibility to ensure our patients make informed decisions regarding cost to their healthcare plans.

Essential Functions, Duties, and Responsibilities

Tasks may include (based on services offered within assigned region), but not limited to the following:

• Accurately verify benefits and eligibility to ensure that our patients can make informed decisions regarding the cost associated with their healthcare plan.

• Act as subject matter expert (SME) and provide training or mentorship to new and/or current employees.

• Research, review, and effectively document benefits and eligibility within our systems.

• Effectively communicate verification information both internally and externally to ensure that coverage is in place and claims are paying accurately.

• Successfully schedule our patients with the goal of exceeding their expectations timely, convenient, and with the right provider or specialist.

• Provides an exceptional level of customer service to referring providers and patients by functioning as central point of contact to determine the most appropriate clinic for the patient and schedule an evaluation within 24 hours.

• Provides a communication hub to and from the company, patients, clinic teams, referring providers, and payers regarding insurance plan and benefit knowledge.

• Act as a resource for insurance-related questions and needs, as a subject-matter expert and specialist in their field.

• Process new patient enrollments in a timely manner ensuring accuracy of data entry and communication of information by being in constant communication with all Spooner clinics in order to facilitate a smooth transition for the patient.

• Develop a seamless relationship between the Central Client Services team and the Revenue Cycle Management team to ensure efficiency and value in reimbursements.

• Obtain initial insurance authorization when required for all new patients/initial evaluations.

• Ensure all patient records are accurate, complete, compliant, current, and managed.

• Performs other duties as assigned.

Qualifications: Education, Experience, and Skills

Required:

• High school diploma or equivalent.

• 5+ years of insurance verification and eligibility and/or authorization experience required.

• Working knowledge of CMS guidelines, contracted insurance guidelines and coding policies.

• Demonstrated knowledge of available community resources, crisis intervention, counseling, advocacy, community relationships, and referral methods.

• Detailed oriented, reliable, and able to multi-task in a fast-paced, high-volume work environment.

• Microsoft Suite and Excel knowledge (intermediate to advanced).

• Ability to maintain a high level of confidentiality (HIPAA guidelines and regulations) and professionalism.

• Must have a valid driver license and be 18 years of age.

• Must have the ability to walk, climb, stoop, reach, crawl, crouch, kneel, push, pull and lift a minimum of 10lbs.

• Must have excellent written and verbal communication, with particular emphasis during telephone calls, follow-ups, and in-person correspondence.

• We are a Second-Chance Employer

• Must be able to pass a seven-year background check.

• Must be able to pass substance abuse testing.

Must be able to pass three-year motor vehicle report and meet minimum eligibility requirements criteria of insurance carrier (if driving is required for this position).

Associated Knowledge, Skills, and Abilities

• Prior training experience is preferred.

• Above average computer skills including databases, spreadsheets, interface file maintenance and related computer programs designed for billing, coding, and accounting purposes.

• Ability to focus on the big picture while attending to multiple detail requirements in a changing environment.

• Ability to analyze and interpret data.

• Ability to formulate, recommend and implement solutions.

• Ability to adapt to change in the workplace and demonstrate the ability to work collectively within a diverse team environment.

• Ability to use critical thinking and reasoning skills to solve a problem.

• Ability to provide guidance and feedback to help others strengthen specific knowledge/skill areas.

Ability to find a solution for or to deal proactively with work-related problems.

Core Job Competencies

To perform the job successfully, an individual should demonstrate the following job competencies:

• Teamwork -- Working as a productive member of a cohesive group toward a common goal and contributing to team development and effective team dynamics.

• Quality of Work -- Degree of proficiency in performing the job; accuracy, neatness, skill, thoroughness, economy of materials.

• Customer Focus -- Knowing the (internal and external) customer business needs and acting; accordingly, anticipating customer needs, and giving high priority to customer satisfaction and customer service.

• Job Knowledge -- Understanding of the job, including procedures, techniques, equipment, etc. Utilized prior training/experience. Acquires the knowledge needed to perform the job.

Accountability -- Accepting responsibility that results in anticipation/prevention of problem areas from actions, and problem solving inside and outside the department/organization.

License/Certification

Preferred:

N/A

Working Environment

Work is performed in a typical interior office setting with moderate noise levels in addition to managing multiple projects at one time that may be interrupted frequently to meet the needs and request of team members, customers, and management or C-level team members.

Working Conditions/Physical Requirements

Physical activities include typing, talking, and hearing in a sedentary work environment. Exerting up to 10 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. The worker is required to have close visual acuity to perform an activity such as: preparing and analyzing data and figures; transcribing; viewing a computer terminal; extensive reading; visual inspection involving small defects, small parts, and/or fabrication parts at distances close to the eyes.

Equipment or Machines Routinely Used in This Position

Required to use keyboard, mouse, and other electronic accessories in addition to fax machines, monitors, computers, laptops, mobile devices, tablets, presentations remotes, televisions, printers, scanners, postage meter, multi-line phone, headset or Bluetooth related devices.

Review Procedures

A regular review and evaluation of the employee's work performance will be conducted.