Insurance Specialist III

Insurance Specialist III – WVU Medicine

We’re excited you’re considering this opportunity! To apply, use the Apply button above and submit your complete application. Below is important information.

• High school graduate or equivalent with 2 years working experience in a medical environment.
• Associate’s degree and 1 year of experience in a medical environment.

• 3 years’ experience understanding and interpreting medical terminology, ICD-10, and CPT codes.
• Understanding of authorization processes, insurance guidelines, and third‑party payer practices.
• Proficiency in Microsoft Office applications.
• Excellent communication and interpersonal skills.
• Ability to prioritize to meet deadlines and multitask with a high level of efficiency and attention to detail.
• Basic computer skills.

• Obtain authorizations for elective infusions and injections to financially clear patients and ensure reimbursement for the organization.
• Use payor resources and reference material to verify prior authorization requirements.
• Escalate financial clearance risks as appropriate in compliance with the Financial Clearance Program.
• Serve as a liaison between clinical teams and pharmacists regarding infusion prior authorization issues.
• Code cases and review clinical documentation to maximize reimbursement.
• Utilize EPIC work queues to manage workloads and prioritize to meet deadlines.
• Collect and communicate outpatient benefit information to the Patient Financial Services team via queues and billing indicators in EPIC.
• Refer to medical and coverage policies for medications and research CPT codes for drugs/injections.
• Verify authorization requirements using insurance portals or by calling insurers.
• Submit authorizations as buy‑and‑bill for outpatient on‑campus hospital requests.
• Review and interpret medical record documentation to answer clinical questions during authorization.
• Communicate with clinics when additional information is needed.
• Use hospital communication systems (fax, pager, telephone, copiers, scanners, and computers) in accordance with standards.
• Follow up daily on submitted authorization requests and peer‑to‑peer scheduling.
• Submit and follow up on prior authorization appeals for denied medications.
• Communicate to appropriate parties when home or pharmacy benefit is needed.
• Verify referrals and authorizations in work queues.
• Identify changes in medication dosing/frequency and assist Patient Financial Services with denial management.
• Maintain baskets in EPIC and emails in Outlook.
• Participate in monthly team meetings and one‑on‑ones.
• Build admissions and submit authorization for elective inpatient chemotherapy admission and observations.
• Follow established workflows, identify deviations or deficiencies, and communicate problems to supervisor or manager.
• Maintain professional and respectful communication with staff, physicians, patients, and families.
• Maintain confidentiality regarding patient and financial information.

• Prolonged periods of sitting.
• Extended periods on the telephone requiring clarity of hearing and speaking.
• Manual dexterity to operate standard office equipment, keyboards, fax machines, telephones, and other equipment.

• Outpatient clinical environment.

• Excellent oral and written communication skills.
• Basic knowledge of medical terminology, ICD-10, CPT coding, and third‑party payors.
• Basic knowledge of business math and time-of-service collection procedures.
• Excellent customer service and telephone etiquette.
• Minimum typing speed of 25 words per minute.
• Reading and comprehension ability.

Job Details:

Schedule:

40 hours per week

Shift: Day (United States of America)
Exempt/Non-Exempt:
Non‑Exempt (United States of America)
Company:
West Virginia University Health System
Cost Center: 536 SYSTEM Hospital Authorization Unit