DME-Ins Verification Spec

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. High school graduate or equivalent.

EXPERIENCE:

1. One (1) year of experience in medical billing, insurance claims processing, home medical equipment, customer service or healthcare field.

PREFERREDQUALIFICATIONS:

EXPERIENCE:

1. Experience in home medical equipment sales. Customer service and insurance coverage.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Receive and review physician orders and documentation from staff to verify it meets medical necessity for items requested against specific insurance criteria. Obtain additional documentation via EPIC or referral as needed.

2. Confirm Insurance eligibility to complete insurance verification to reflect the most up to date coverage benefits: Medicaid, Medicarevs. Medicare Advantage plan coverage or Third Party Liability (MSP).

3. Check for existing CMNs for Medicare customers using same/similar function to avoid denial of equipment.

4. Submit documentation to insurance payers (such as Medicaid, Advantage plans, etc.) as needed for preauthorization through fax or payer website. Provide daily follow-up on requests.Note accounts appropriately, once authorization is approved or denied and task note to the appropriate staff.

5. Obtain certificate of medical necessity (CMN) for Medicaid (and other assigned plans) to include continued follow-up with practices as needed for initial and continued authorization for services.

6. PAP compliance - review note assignments from Respiratory Therapists and reports, obtain continued authorization for pap equipment as needed. Work with assigned staff and/or patients to return equipment if non-compliant or arrange financial options.

7. Work "Task" follow-ups and WIP's as required in a timely fashion.

8. Work various reports as assigned: PAR expiring report, Medicare RUL oxygen report, Medicare 65 eligibility report, Stop Hold report look for commercial, Medicaid, Medicare Policy Change, Policy Expire and Multi Price Issues.Verify new coverage, contact beneficiary to get requalified or issue pickup tickets.

9. Cross train with Patient Intake Specialists and customer service to serve as back up, including Hospice orders.

10. Answers phone calls from referrals and customers with questions regarding authorization or insurance coverage criteria as needed.Assists accounts receivable with documentation as needed.

11. Involves understanding all payor guidelines as they relate to the insurance coverage, co-pays, co-insurance, out of network benefits, out of pocket requirements, identifying if a and when a pre-authorization (PAR) is required, ensuring the patient, the HCPCS, and the quantities are all covered and information customer service when items and/or quantities are non-covered, so the customer service team can have the appropriate financial responsibility conversations with the patient and/or caregiver.

12. Conduct insurance verifications via the appropriate insurance portals, and/or via electronic verification methods, based on business rules

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Sedentary to light physical demands.

2. Frequent sitting.

3. Able to lift, carry, pulling and holding up to a light range (10-20lbs).

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Typical office environment.

SKILLS AND ABILITIES:

1. Able to use computer software, fax machines, printers and other office equipment.

2. Strong communication skills.

3. Strong customer service skills.

Additional Job Description:

Scheduled Weekly Hours:

Shift:

Exempt/Non-Exempt:

Company:

Cost Center:

Address:

Equal Opportunity Employer

West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.