Medicare Continued Qualification Specialist Job Blue Bell Pennsylvania USA,Healthcare

Location: Blue Bell

A Continued Qualification "Medicare" Specialists primary responsibility is to obtain all necessary documentation required by the patients insurance provider to continue qualified and authorized use of Ethos therapy products. This position plays a critical role in ensuring the seamless coordination of continued or transitioned therapy, facilitating efficient billing processes, and minimizing financial burdens for the payer, the patient and the product provider (Ethos).

The role requires strong communication skills, a solid understanding of insurance policies and procedures, and the ability to work collaboratively with various stakeholders including patients, caregivers, clinical referral and payer sources. The team protects compliance, supports accurate Medicare billing, prevents denials, and ensues every support surface claim remains fully supported throughout the patient's course of treatment.

The Continued Qualification Medicare Specialist team moto is:
Qualify the patient, support the need, verify continued use, and keep the file audit-ready every day.

Qualifications

Responsibilities:

Products:
Acquire a deep understanding of Ethos products and their application and benefit to patient healing in the home.

Communication:

A) Routine/scheduled contact with patients to verify active and compliant use of therapy products, active insurance coverage, and active healthcare providers.

B) Routine/scheduled contact with health care providers to obtain payer required documentation to maintain therapy in the home.

C) Routine/scheduled contact with in-house stakeholders to coordinate necessary and timely product transitions based on patients' eligibility for specific therapy determined by insurance guidelines and coverage limitations.

Documentation:
Maintain accurate and real-time records of clinical visits, patient assessments, patient demographics, insurance information, authorizations, coverage details and communication trail in digital platforms or designated database.

Eligibility Assessment:
Assess patients' eligibility for specific therapy determined by insurance clinical/compliance guidelines and coverage or contract limitations.

Insurance Reauthorization:
Perform necessary and timely reauthorization of patients' insurance coverage for continued therapy in the home, including reviewing clinical/compliance eligibility criteria, insurance plans, and benefits.

Escalation:
Timely escalate cases that have or could result in delayed claims submission or unbilled claims such as product transitions, non-compliance, denied appeals.

Claim Processing:
Collaborate with the billing department to ensure accurate and timely claim submissions, including the completion of necessary documentation and adherence to insurance company requirements.

Problem Resolution:
Investigate and resolve insurance-related issues, such as denied reauthorization claims and delays by working closely with insurance companies, patients, healthcare providers and in-house stakeholders.

Compliance:
Adhere to federal and state regulations, as well as insurance policies and guidelines, to maintain accurate and ethical practices in insurance reauthorization processes.

Continuous Improvement:
Identify opportunities for process improvements and collaborate with the team to enhance efficiency and effectiveness in continued qualification procedures.

Qualifications:

High school diploma or equivalent; additional education in healthcare administration, medical billing, or related fields is preferred.
Direct Medicare experience required.
Proven experience in insurance verification within a medical or healthcare setting.
Comprehensive knowledge of various insurance plans, including private insurance, Medicare, Medicaid, and managed care organizations.
Famili…