Insurance Specialist-6027

• Serves as Primary Contact for all payer requests for clinical information and utilization review decisions, in an efficient and professional manner.
• Serves as primary communicator to Case Managers, Physicians and Physician Advisors when clinical information if requested/received from the payor.
• Obtains and tracks appropriate information from Case Managers/Utilization Review Nurses and transmits to payers via fax, phone, or email, within the timeframe determined by the payer. 
• Tracks cases to ensure authorization is received from the payer within 24 to 48 hours.
• Communicates authorization information to Case Manager/Utilization Review Nurse and updates information into the EMR and ARM module. 
• Arranges and tracks Peer-to-Peers for physicians and works medical necessity denials in a timely manner.
• Demonstrates EMR and ARM module notes are concise and accurately reflects the activity and outcome.

Education:  High School Diploma or GED Equivalent

Experience:  N/A

Certification:  N/A

License:  N/A

Knowledge, Skills, and Abilities: 

• Experience with office machines (i.e., copier, fax, telephone), computer terminal/personal computer, software and payor portals (i.e., word processing, spreadsheets, etc.)
• Strong oral and written communication skills, must have excellent attention to detail as well as superb interpersonal skills in interacting with payers and healthcare team members

Education:  Associate degree or higher in business or healthcare related field

Experience:  2 years of experience in a healthcare setting performing related duties such as insurance claims, utilization review, doctor’s office, DME, etc.

Certification:  N/A

License:  N/A

Knowledge, Skills, and Abilities:

• Expertise and knowledge of third-party payer requirements and regulations including Medicare/Medicaid, managed care payers, commercial insurance companies, worker’s comp, etc. 
• Knowledge and expertise in developing and using data management tools such as Excel, Access, etc

Exposure Category II: Expected duties have possible, but not routine, potential for exposure to blood, body fluids, or tissues

Other potential Hazard(s): Volatile/violent patients or family members

• Able to handle multiple priorities simultaneously
• Ability to sit for 3-5 hours per day
• Ability to stand for 3-5 hours per day
• Ability to walk for 3-5 hours per day