Insurance Verification Specialist

The Insurance Verification Specialist coordinates and performs insurance verification confirming patient participation in health plan and obtains accurate benefit coverage. Validates or obtains pre‑certification requirements with the rendering physician’s office, third party carriers, and managed care providers as required by the patient’s medical coverage. Contacts patients to advise them of co‑pays and deposits as needed. Discusses pre‑existing or benefit limitations with patients, provides professional, accurate, and timely service in all admitting functions and as requested by patients/families, physicians, visitors, or other hospital representative.

This position does not directly manage any other caregivers.

• Confirms patient participation in health plan and obtains accurate benefit coverage. Establishes co‑pay, deductible, and co‑insurance amounts, deposits and max out‑of‑pocket in accordance with St. Charles Health System credit and collection guidelines.
• Communicates appropriate provider and facility information to health plan as part of the prior authorization or admission notification process. Has intermediate patient access knowledge of registration & insurance within the EMR.
• Maintains working knowledge of Medicare, Medicaid, Commercial and HMO payors. Remains current on all insurance company changes/requirements applying authorization requirements. Assists physician offices in completing authorization requirements for an accurate authorization.
• Submits documentation to obtain authorizations, verifies authorizations that are in place and accurate for procedures. Provides notice of observation or admission for applicable services.
• Contacts physician’s office when authorization is missing or inaccurate. Tracks, updates and investigates current orders and tasks; managing orders through the system to provide up‑to‑date and accurate information. Obtains pertinent documentation from provider, facility and patient to ensure accurate prior authorization and patient assistance requests. Assists with patient education and follow‑up regarding the prior authorization and referral processes.
• Starts the utilization management and continued stay review workflow by submitting notification to insurance companies for our bedded outpatients and inpatients within required timelines. Confirms with insurance companies whether ICD‑10, HCPCS codes and type of stay ordered require an authorization and that physician’s office has obtained authorization or certifications when necessary.
• Monitors and complies with regular changes by insurance companies. Ensures St. Charles Health System meets insurance requirements, and ultimately gets paid for services rendered with the highest level of accuracy.
• Provides estimates of cost for procedures and services.
• Prepares required waivers on accounts for non‑covered services, or as required by government plan. Notes the EMR with accurate benefit information. Notifies appropriate department where patient will arrive, to ensure waiver/ABN compliance on day of service. Develops and keeps updated waivers forms, insurance notes, policies and procedures. Documents activity within the EMR regarding all calls, correspondence, and related activities to each patient account, to assist other departments in understanding patients’ coverage and patient responsibility.
• Refers patients to SCHC financial assistance programs as needed. Provides patients with applications for St. Charles Health System Financial Assistance Program when appropriate. Assists with review, tracking and correction of denied claims. Uses electronic tools to discover insurance for self‑pay patients.
• Performs duties in accordance with department guidelines, seeks direction for issues outside guidelines.
• Works in partnership with Utilization Management, Surgery Scheduling, Documentation Coordinators, Pre‑Surgery Clinics, Billing, and Chargemaster.
• Supports the vision, mission and values of the organization in all respects.
• Supports the Lean principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.
• Provides and maintains a safe environment for…