Continued Qualification "Medicare" Specialist - Blue Bell, PA

Continued Qualification "Medicare" Specialist

A Continued Qualification "Medicare" Specialist's primary responsibility is to obtain all necessary documentation required by the patient's insurance provider to continue qualified and authorized use of Ethos therapy products. This position plays a critical role in ensuring the seamless coordination of continued or transitioned therapy, facilitating efficient billing processes, and minimizing financial burdens for the payer, the patient and the product provider (Ethos). The role requires strong communication skills, a solid understanding of insurance policies and procedures, and the ability to work collaboratively with various stakeholders including patients, caregivers, clinical referral and payer sources. The team protects compliance, supports accurate Medicare billing, prevents denials, and ensures every support surface claim remains fully supported throughout the patient's course of treatment.

The Continued Qualification Medicare Specialist team motto is: Qualify the patient, support the need, verify continued use, and keep the file audit-ready every day.

Qualifications

Key Performance Expectations for the Medicare CQ Specialist:

• Maintain monthly clinical documentation.
• Identify documentation deficiencies promptly.
• Communicate effectively with provider offices.
• Prevent unsupported claims from billing.
• Maintain audit-ready files.
• Support billing compliance.
• Protect the company from Medicare recoupments and denials.
• Ensure patients continue receiving medically necessary equipment.

Responsibilities:

Products: Acquire a deep understanding of Ethos products and their application and benefit to patient healing in the home.

Communication: Routine/scheduled contact with patients to verify active and compliant use of therapy products, active insurance coverage, and active healthcare providers. Routine/scheduled contact with health care providers to obtain payer required documentation to maintain therapy in the home. Routine/scheduled contact with in-house stakeholders to coordinate necessary and timely product transitions based on patients' eligibility for specific therapy determined by insurance guidelines and coverage limitations.

Documentation: Maintain accurate and real-time records of clinical visits, patient assessments, patient demographics, insurance information, authorizations, coverage details and communication trail in digital platforms or designated database.

Eligibility Assessment: Assess patients' eligibility for specific therapy determined by insurance clinical/compliance guidelines and coverage or contract limitations.

Insurance Reauthorization: Perform necessary and timely reauthorization of patients' insurance coverage for continued therapy in the home, including reviewing clinical/compliance eligibility criteria, insurance plans, and benefits.

Escalation: Timely escalate cases that have or could result in delayed claims submission or unbilled claims such as product transitions, non-compliance, denied appeals.

Claim Processing: Collaborate with the billing department to ensure accurate and timely claim submissions, including the completion of necessary documentation and adherence to insurance company requirements.

Problem Resolution: Investigate and resolve insurance-related issues, such as denied reauthorization claims and delays by working closely with insurance companies, patients, healthcare providers and in-house stakeholders.

Compliance: Adhere to federal and state regulations, as well as insurance policies and guidelines, to maintain accurate and ethical practices in insurance reauthorization processes.

Continuous Improvement: Identify opportunities for process improvements and collaborate with the team to enhance efficiency and effectiveness in continued qualification procedures.

Qualifications:

High school diploma or equivalent; additional education in healthcare administration, medical billing, or related fields is preferred. Direct Medicare experience required. Proven experience in insurance verification within a medical or healthcare setting. Comprehensive knowledge of various insurance plans, including private insurance, Medicare, Medicaid, and managed care organizations. Familiarity with medical terminology, CPT codes, and ICD-10 coding system. Proficient in using electronic health records (EHR) systems, insurance databases, and billing software. Strong attention to detail with clear and concise written communication skills, excellent organizational skills, and the ability to stay on task. Exceptional customer service skills, with the ability to verbally build relationships with various stakeholders. Ability to work collaboratively with a diverse team including in-house staff, healthcare professionals, insurance representatives, and patients. Proficiency in problem-solving and conflict resolution in insurance-related matters. Knowledge of HIPAA regulations and commitment to maintaining patient confidentiality.

Physical Requirements: Must be able to remain in a stationary position for extended periods of time. Ability to sit or stand for extended periods of time. Constantly operates a computer and other office productivity machinery, such as a copy machine and computer printer. Ability to travel occasionally by car or commercial flight.

Ethos Therapy Solutions is an equal opportunity employer and does not discriminate against any employee or applicant for employment based on race, color, religion, national origin, age, gender, sex, ancestry, citizenship status, mental or physical disability, genetic information, sexual orientation, gender identity, veteran status, or military status. Ethos Therapy Solutions complies with all applicable federal, state and local laws concerning non-discrimination.