Insurance Specialist

Sioux Center Health; Pierre (SD); On-site; USD 2,686,000 - 3,513,000; Full time

Benefits offered by this job

PTO available day 1 for eligible hires

Up to 5% employer matching retirement

Career development and mentorship

Job summary

Avera St Mary's Hospital in Pierre, SD, is looking for an Insurance Eligibility and Authorization Specialist to verify coverage, secure authorizations, and estimate patient financial responsibility to prevent denials and optimize reimbursement.

You will work with multiple departments to ensure accurate information, maintain compliance with HIPAA/EMTALA, and communicate payment expectations to patients and families as part of a compassionate care team.

Qualifications

• Required: 1-3 years related experience in billing, insurance or registration.
• Required: 1-3 years healthcare experience.
• Preferred: Associate's finance, business or healthcare.

Responsibilities

• Process eligibility and secure full benefit coverage information with insurance companies and employers, confirm demographic information is correct, and ensure coordination of benefit and plan codes are accurate.
• Identify all payment sources for accurate primary and secondary payer coverage and required authorizations to prevent denials.
• Obtain necessary referrals, authorizations and pre-certifications from physicians and payers and enter information into the health information system.
• Collects and validates accurate patient demographic and insurance information, verifies insurance, obtains pre-certification/authorization as required and enters information.
• Calculate and communicate patient estimates for hospital services using a deposit matrix to determine estimated patient responsibility.
• Educate patients on benefits, offer payment options, identify needs for financial assistance and provide charity applications.
• Screen self-pay patients for potential payer coverage and direct accounts to advocacy team for review.
• Provide communication concerning changes in insurance coverage prior to billing.
• Maintain professional development and compliance with regulations (CMS, HIPAA, EMTALA) as they pertain to insurance processes.

Education

Associate's finance, business or healthcare.

Job description

Pay Range

$19.50 - $25.50

Location

Avera St Mary's Hospital

Worker Type

Regular

Work Shift

Day Shift (United States of America)

Position Highlights

You Belong at Avera. Be part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. Work where you matter.

A Brief Overview

Responsible for ensuring insurance eligibility, benefit verification, and the authorization processes are complete in the time allowed by the insurance companies to prevent denials or penalties. Specialists are responsible for documenting accurate insurance information and authorization details to optimize reimbursement from both the payer and patient. The Specialist must maintain strong working knowledge of insurance plans, contract requirements, and resources to facilitate appropriate insurance verification and authorization. Specialists must also be able to understand and interpret patient liability and benefits for all payer types including copays, co‑insurance, and out‑of‑pocket responsibilities in order to provide patients and families with information on their financial responsibility. The Specialist will calculate and communicate to the patient a financial responsibility estimation, provide charity applications and/or direct the patient to the business office for payment and assistance options. The Specialists will collect patient liability prior to service and attempt to collect prior balances. The Specialist collaborates with various other departments to ensure proper reimbursement on accounts. The Specialists are to conduct all transactions appropriately and consistently, and complete government regulatory forms accurately with the patient or patient’s representative. Specialists must maintain compliance with government regulations (i.e. EMTALA and HIPAA) as it pertains to the insurance process.

What You Will Do

• Process eligibility and secure full benefit coverage information (including COBRA when applicable) with insurance companies and employers, confirm all demographic information is correct, and ensure coordination of benefit (COB) and insurance plan codes are accurate. Specialists must verify insurance coverage immediately for inpatient and outpatient accounts that are same day and next day add-ons.
• Identify all payment sources for accurate primary and secondary payer coverage and required authorizations to prevent denials and/or reduction in payment for patients entering the facility for care.
• Obtain necessary paper/electronic referrals, authorizations and pre-certifications from Primary Care Physician and/or Specialty Physician when required by payers, Managed Care, and traditional Medicaid and enters information into the health information system.
• Collects and validates accurate patient demographic and insurance information, verifies insurance, obtains pre-certification/authorization as required and enters all necessary information.
• Calculate and communicate patient estimates for hospital services utilizing a deposit matrix or patient payment estimator to determine estimated patient responsibility and communicates financial expectations to the patient.
• Educates patients on their benefits, offers the patient/family the opportunity to pay their estimated patient responsibility prior to services rendered, and identifies methods of payment available. Identifies patients in need of financial assistance and provides charity applications and referrals to the business office as necessary.
• Responsible to screen all self pay patients for potential payer coverage and directs applicable accounts to the advocacy team for further review. Assure all payer requirements are met, including non‑coverage waivers, Advance Beneficiary Notices, sterilization forms, and other forms as applicable.
• Provide communication concerning change of insurance coverage, prior to billing, from Registration staff and/or Patient Advocate/Billing staff.
• Maintain professional development by attending workshops, in‑services, and webinars to remain up‑to‑date on insurance rules and regulations in addition to changes within the industry.

Essential Qualifications

The individual must be able to work the hours specified. To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge, skills, and abilities required to perform the essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions, as long as the accommodations do not cause undue hardship to the employer.

Required Education, License/Certification, Or Work Experience

• 1-3 years Related experience in billing, insurance or registration.
• 1-3 years Healthcare experience

Preferred Education, License/Certification, Or Work Experience

• Associate's finance, business or healthcare.

Expectations and Standards

• Commitment to the daily application of Avera's mission, vision, core values, and social principles to serve patients, their families, and our community.
• Promote Avera's values of compassion, hospitality, and stewardship.
• Uphold Avera's standards of Communication, Attitude, Responsiveness, and Engagement (CARE) with enthusiasm and sincerity.
• Maintain confidentiality.
• Work effectively in a team environment, coordinating work flow with other team members and ensuring a productive and efficient environment.
• Comply with safety principles, laws, regulations, and standards associated with, but not limited to, CMS, The Joint Commission, DHHS, and OSHA if applicable.

Benefits You Need & Then Some

• PTO available day 1 for eligible hires.
• Up to 5% employer matching contribution for retirement
• Career development guided by hands‑on training and mentorship

Equal Opportunity Employer

Avera is an Equal Opportunity Employer - Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, Veteran Status, or other categories protected by law. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-605-504-4444 or send an email to [e-mail].