Specialist

Job Description

Responsibilities: 

• Acquire insurance benefit coverage via phone or online portal 
• Interpret benefit coverage information to determine anticipated costs for clients 
• Use discernment and judgment to evaluate the accuracy, completeness, and reliability of insurance benefit information and identify discrepancies or gaps requiring additional verification
• Assess case viability by evaluating expected reimbursement, payor requirements, funding criteria, and the likelihood of successful reimbursement prior to initiating a trial.
• Determine device trial funding options based on the patient’s insurance coverage 
• Recognize and identify potential coordination of benefits (COB) issues and proactively engage with the patient and/or care partner to gather information and assist in resolving discrepancies. 
• Review benefits for accuracy prior to sale 
• Clearly communicate funding determinations, potential barriers, and recommended next steps clearly to internal teams and, when appropriate, patients and care partners.
• Maintain accurate, complete, and compliant documentation of insurance verification, funding determinations, patient records, and related communications in accordance with HIPAA, Medicare, and organizational requirements.
• Proactively communicate with team members regarding identified potential issues and concerns 
• Maintain patient records according to HIPAA and Medicare guidelines 
• Track and trend issues to aid in the resolution and prevention of repeat problems 
• Complete all administrative functions, such as data entry, associated with sales activities in a timely manner and in accordance with established processes 
• Identify and escalate priority issues and proactively follow up on tasks 
• Perform other duties and special projects as assigned 

Qualifications

Skills and Competencies: 

• Knowledge of insurance plans, funding sources, and reimbursement processes related to Durable Medical Equipment (DME).
• Strong data entry, documentation, and organizational skills with a high level of accuracy and attention to detail.
• Methodical approach to gathering information, conducting research, and resolving issues effectively.
• Effective verbal and written communication skills with a professional, customer-focused approach.
• Compassion for individuals with disabilities and the ability to communicate effectively with clients who have speech impairments.
• Ability to build rapport and maintain professionalism when interacting with clients, caregivers, providers, and internal stakeholders.
• Strong critical thinking and problem-solving skills, with the ability to assess risk and make informed decisions.
• Ability to exercise sound independent judgment within established guidelines and appropriately escalate complex or high-risk situations.
• Ability to identify alternative solutions, evaluate options, and recommend appropriate courses of action.
• Demonstrates adaptability in response to changing priorities, processes, and business needs.
• Exhibits innovative thinking and a willingness to explore new approaches to improve outcomes and efficiency.
• Open to giving and receiving feedback, with a commitment to continuous learning and professional growth.
• Ability to manage multiple priorities and maintain consistent performance in a fast-paced, process-driven environment.
• Strong attention to detail while balancing productivity, quality, and timeliness.
• Maintains a sense of urgency and takes ownership of responsibilities through to resolution.
• Proactive, solutions-oriented mindset with the ability to anticipate challenges and address them effectively.
• Demonstrates accountability, follow-through, and ownership of assigned work.
• Takes initiative to identify opportunities for improvement and contribute to team and organizational success.

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