Job Description

Job Duties and Responsibilities:

• Verify the patient’s medical and pharmacy coverage.
• Responsible to provide the patient benefits, code the patient’s insurance/s, and run test claims for pharmacy if applicable.
• Initiate outbound calls to Insurances to validate benefit information, as necessary.
• Responsible for verifying the member's primary insurance.
• Maintains accurate and detailed records in company database.
• Adapts quickly to frequent process changes and improvements.
• Is reliable, engaged, and provides feedback to improve processes and policies.
• Adapts quickly to frequent process changes and improvements.
• Is reliable, engaged, and provides feedback to improve processes and policies.
• Attends all department, team, and weekly company meetings as required.
• Perform any additional responsibilities or special projects as required.
• Duties and responsibilities may be subject to change based upon the needs of the department Assist with hiring of entry-level customer service employees.
• Verify eligibility requirements on Durable Medical Equipment (DME) for Urological and Catheter products, Incontinence supplies, thickeners, and nutritional supplements, Breast pumps and other healthcare related products for 150+ insurances/Payers.
• Insurance Verification (IV)
  Receive and review new patient orders, referrals, and reorder requests requiring benefit verification.
  b. Verify patient demographics and active insurance coverage across all payer types (Commercial, Medicare, Medicare Advantage, Medicaid, and other plans).
  c. Confirm eligibility, effective dates, and coordination of benefits (COB) where applicable.
  d. Identify plan-specific requirements, including prior authorization needs, documentation requirements, and referral criteria.
• Benefits & Coverage Determination
  Validate covered services and product eligibility based on payer guidelines and diagnosis.
  b. Determine patient financial responsibility, including deductibles, co-pays, co-insurance, and out-of-pocket maximums.
  c. Review frequency limitations, quantity limits, and replacement guidelines for applicable products.
  d. Document detailed benefit breakdowns in system of record (e.g., Brightree or applicable EMR/DME platform).

Job Required Qualification:

• Minimum 3-year solid experience with US Healthcare Insurance
• At least 1 year work experience in a customer service call center (Voice and Back office)
• Experience with medical Insurance/Benefits investigation and Authorizations is highly preferred.
• Excellent Customer service skills, including phone and interpersonal skills.
• Computer proficiency in MS Word, Excel, and Outlook preferred
• Typing accuracy of 35 wpm minimum
• Database data entry experience preferred.
• Strong knowledge and use of the English language, both written and verbal
• Work history of excellent attendance and punctuality
• High comfort level working with culturally diverse team members and clients.
• Proficient mathematical skills, including addition, subtraction, multiplication, and division.

Preferred Qualifications:

• Startup / rapid growth experience
• Life sciences, pharmaceutical, or medical device experience.
• Knowledge of medical terminology preferred.
• Knowledge Durable Medical Equipment