WVU Medicine
Insurance Specialist III – WVU Medicine
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Minimum Qualifications
High school graduate or equivalent with 2 years working experience in a medical environment.
Associate’s degree and 1 year of experience in a medical environment.
Preferred Qualifications
3 years’ experience understanding and interpreting medical terminology, ICD-10, and CPT codes.
Understanding of authorization processes, insurance guidelines, and third‑party payer practices.
Proficiency in Microsoft Office applications.
Excellent communication and interpersonal skills.
Ability to prioritize to meet deadlines and multitask with a high level of efficiency and attention to detail.
Basic computer skills.
Core Duties and Responsibilities
Obtain authorizations for elective infusions and injections to financially clear patients and ensure reimbursement for the organization.
Use payor resources and reference material to verify prior authorization requirements.
Escalate financial clearance risks as appropriate in compliance with the Financial Clearance Program.
Serve as a liaison between clinical teams and pharmacists regarding infusion prior authorization issues.
Code cases and review clinical documentation to maximize reimbursement.
Utilize EPIC work queues to manage workloads and prioritize to meet deadlines.
Collect and communicate outpatient benefit information to the Patient Financial Services team via queues and billing indicators in EPIC.
Refer to medical and coverage policies for medications and research CPT codes for drugs/injections.
Verify authorization requirements using insurance portals or by calling insurers.
Submit authorizations as buy‑and‑bill for outpatient on‑campus hospital requests.
Review and interpret medical record documentation to answer clinical questions during authorization.
Communicate with clinics when additional information is needed.
Use hospital communication systems (fax, pager, telephone, copiers, scanners, and computers) in accordance with standards.
Follow up daily on submitted authorization requests and peer‑to‑peer scheduling.
Submit and follow up on prior authorization appeals for denied medications.
Communicate to appropriate parties when home or pharmacy benefit is needed.
Verify referrals and authorizations in work queues.
Identify changes in medication dosing/frequency and assist Patient Financial Services with denial management.
Maintain baskets in EPIC and emails in Outlook.
Participate in monthly team meetings and one‑on‑ones.
Build admissions and submit authorization for elective inpatient chemotherapy admission and observations.
Follow established workflows, identify deviations or deficiencies, and communicate problems to supervisor or manager.
Maintain professional and respectful communication with staff, physicians, patients, and families.
Maintain confidentiality regarding patient and financial information.
Physical Requirements
Prolonged periods of sitting.
Extended periods on the telephone requiring clarity of hearing and speaking.
Manual dexterity to operate standard office equipment, keyboards, fax machines, telephones, and other equipment.
Working Environment
Outpatient clinical environment.
Skills and Abilities
Excellent oral and written communication skills.
Basic knowledge of medical terminology, ICD-10, CPT coding, and third‑party payors.
Basic knowledge of business math and time-of-service collection procedures.
Excellent customer service and telephone etiquette.
Minimum typing speed of 25 words per minute.
Reading and comprehension ability.
Job Details: Schedule: 40 hours per week Shift: Day (United States of America) Exempt/Non-Exempt: Non‑Exempt (United States of America) Company: West Virginia University Health System Cost Center: 536 SYSTEM Hospital Authorization Unit
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Minimum Qualifications
High school graduate or equivalent with 2 years working experience in a medical environment.
Associate’s degree and 1 year of experience in a medical environment.
Preferred Qualifications
3 years’ experience understanding and interpreting medical terminology, ICD-10, and CPT codes.
Understanding of authorization processes, insurance guidelines, and third‑party payer practices.
Proficiency in Microsoft Office applications.
Excellent communication and interpersonal skills.
Ability to prioritize to meet deadlines and multitask with a high level of efficiency and attention to detail.
Basic computer skills.
Core Duties and Responsibilities
Obtain authorizations for elective infusions and injections to financially clear patients and ensure reimbursement for the organization.
Use payor resources and reference material to verify prior authorization requirements.
Escalate financial clearance risks as appropriate in compliance with the Financial Clearance Program.
Serve as a liaison between clinical teams and pharmacists regarding infusion prior authorization issues.
Code cases and review clinical documentation to maximize reimbursement.
Utilize EPIC work queues to manage workloads and prioritize to meet deadlines.
Collect and communicate outpatient benefit information to the Patient Financial Services team via queues and billing indicators in EPIC.
Refer to medical and coverage policies for medications and research CPT codes for drugs/injections.
Verify authorization requirements using insurance portals or by calling insurers.
Submit authorizations as buy‑and‑bill for outpatient on‑campus hospital requests.
Review and interpret medical record documentation to answer clinical questions during authorization.
Communicate with clinics when additional information is needed.
Use hospital communication systems (fax, pager, telephone, copiers, scanners, and computers) in accordance with standards.
Follow up daily on submitted authorization requests and peer‑to‑peer scheduling.
Submit and follow up on prior authorization appeals for denied medications.
Communicate to appropriate parties when home or pharmacy benefit is needed.
Verify referrals and authorizations in work queues.
Identify changes in medication dosing/frequency and assist Patient Financial Services with denial management.
Maintain baskets in EPIC and emails in Outlook.
Participate in monthly team meetings and one‑on‑ones.
Build admissions and submit authorization for elective inpatient chemotherapy admission and observations.
Follow established workflows, identify deviations or deficiencies, and communicate problems to supervisor or manager.
Maintain professional and respectful communication with staff, physicians, patients, and families.
Maintain confidentiality regarding patient and financial information.
Physical Requirements
Prolonged periods of sitting.
Extended periods on the telephone requiring clarity of hearing and speaking.
Manual dexterity to operate standard office equipment, keyboards, fax machines, telephones, and other equipment.
Working Environment
Outpatient clinical environment.
Skills and Abilities
Excellent oral and written communication skills.
Basic knowledge of medical terminology, ICD-10, CPT coding, and third‑party payors.
Basic knowledge of business math and time-of-service collection procedures.
Excellent customer service and telephone etiquette.
Minimum typing speed of 25 words per minute.
Reading and comprehension ability.
Job Details: Schedule: 40 hours per week Shift: Day (United States of America) Exempt/Non-Exempt: Non‑Exempt (United States of America) Company: West Virginia University Health System Cost Center: 536 SYSTEM Hospital Authorization Unit
#J-18808-Ljbffr