Verification of Benefits Specialist - MM25

Job Title: Verification of Benefits Specialist
Location (On-site, Remote, or Hybrid?): Plano, TX (onsite)
Contract Duration: Contract until 04/16/2027
Working hours: Mon – Friday 8:00am-5:00 PM
Total hours: 40

As a PTA Specialist you are responsible for facilitating and assisting patients with the pre-certification, pre-determination and authorization process necessary as a prerequisite to perform various procedures or forms of therapy based on physician recommendation.

WHAT YOU’LL DO

• Assist with multiple levels of appeal in the event of initial coverage denial.
• Forward authorized confirmation for procedure to designated patient provider. In addition, this position will provide in-servicing to new patient providers surrounding the pre-authorization process.
• Responsible for managing multiple cases simultaneously within specific time frames
• Follow all policies and procedures related to performing the job role adhering to all data use, storage and privacy policies as outlined.
• Verify benefits, complete authorization requests promptly
• Timely follow up for requested authorizations
• For each procedure, audit required clinical documents for completeness and accuracy
• Obtain authorization for the facility, equipment and physician to perform various procedures from the insurance carrier
• Work with key provider contacts to obtain required clinical information for authorizations
• Work with respective carrier’s utilization review department to obtain appropriate authorizations
• Work within established guidelines when necessary to process appeal for denied requests
• Train patients and their designated providers on pre-authorization processes and requirements, in person or by phone
• Work individually and in a team environment to educate assigned Field Territory Managers and Clinical Specialists

EDUCATION AND EXPERIENCE YOU’LL BRING
Required

• Associate degree in Nursing/Home Health (LVN/LPN) or related field required.
• Minimum of 2 plus yrs experience in a utilization (medical approval) environment or similar work experience

Preferred

• Knowledge of private insurance, Worker’s Compensation and Medicare guidelines pertaining to Prospective and Retrospective Utilization Review.
• Experience in medical device or DME Billing a plus
• Proficient with Microsoft Office (Word & Excel specifically)
• Medical billing software experience a plus
• Knowledge of current CPT codes and familiarity with ICD-10CM (diagnosis coding)
• Ability to accurately meet required time frames/deadlines
• Ability to work as a team player and share workloads with other team members
• Excellent verbal and written communication skills
• Ability to train/present concepts to others