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Job Description
The Insurance Verification & Authorization Specialist is responsible for verifying insurance coverage, obtaining authorizations, and ensuring accurate documentation for patients receiving home health and hospice services. This role serves as a key liaison between insurance companies, clinical teams, financial counselors, and other internal departments to facilitate timely access to care while maintaining compliance with payer requirements. The Specialist supports operational efficiency through proactive communication, management of Epic work queues, data integrity initiatives, and ongoing monitoring of authorization requirements throughout the patient's episode of care.
Principal Accountabilities:
Communication & Coordination:
Serve as a liaison between external insurance companies and internal staff to ensure patient needs are met. Communicate with Clinical Admission Coordinators (CAC), clinicians, and other departments regarding insurance verification and authorization requirements. Notify appropriate team members when patient updates, documentation, or follow-up actions are required. Collaborate with clinical teams to obtain necessary clinical information for ongoing authorizations and payer requests. Facilitate timely communication regarding authorization status and payer requirements.
Insurance Verification:
Verify insurance eligibility and benefits for all incoming referrals across multiple payer sources. Re-verify insurance coverage when payer changes occur or when re-verification is required during the course of care. Participate in annual re-verification activities during open enrollment and other designated periods. Accurately document verification findings within Epic to ensure visibility for clinical, financial, and operational teams. Maintain current knowledge of insurance plans, payer guidelines, and coverage requirements.
Authorization Management:
Obtain timely initial authorizations and precertifications for services requiring payer approval. Manage pending authorizations and ensure accurate system documentation. Demonstrate knowledge of payer-specific authorization requirements and supporting documentation needs. Obtain ongoing authorizations and reauthorizations for home health and hospice services through online portals, telephone communication, or fax submission. Review authorization requests for completeness, accuracy, and required clinical documentation. Request, compile, and submit supporting clinical information necessary for authorization approvals. Document all authorization activity in Epic to support clinical communication and workflow management.
Department Operations:
Maintain coverage of departmental responsibilities during assigned business hours. Manage assigned patient, insurance, and account work queues to ensure timely completion. Support data integrity initiatives through report review, auditing, and correction of discrepancies. Assist with payer changes, retroactive authorizations, and insurance corrections as needed. Participate in Electronic Visit Verification (EVV) processes and other departmental initiatives as directed. Contribute to process improvement efforts that enhance workflow efficiency and patient service.
Education:
High School Diploma or GED required. Associate's or Bachelor's degree in Healthcare Administration, Business, Finance, or related field preferred.
Experience:
Minimum of 2 years of healthcare insurance verification, authorization, patient access, revenue cycle, billing, or related healthcare experience required. Home Health, Hospice, Managed Care, or Health System experience preferred. Experience working with multiple payer sources including Medicare, Medicaid, Commercial Insurance, and Managed Care plans preferred. Prior experience using Epic strongly preferred. Knowledge, Skills & Abilities Strong knowledge of insurance verification, precertification, authorization, and reimbursement processes. Understanding of Medicare, Medicaid, Managed Care, and commercial insurance requirements. Excellent organizational skills with the ability to manage multiple priorities and deadlines. Strong analytical and problem-solving abilities. Exceptional verbal and written communication skills. Ability to collaborate effectively with clinical, operational, and financial teams. High attention to detail and commitment to data accuracy. Proficiency with Epic and Microsoft Office applications preferred.
