Patient Services Specialist

Health Insurance Specialist

The Health Insurance Specialist plays a critical role in ensuring financial stability and operational efficiency by proactively managing insurance verification, authorization processes, and denial mitigation. This position directly supports timely revenue cycle operations and enhances the patient experience through accurate financial transparency and service excellence.

Insurance Verification & Eligibility Management

• Ensure 48-hour compliance for insurance eligibility verification and maintain real-time dashboards for re-verification and insurance changes.
• Support same-day verification for clinic care models and add-on scheduling to ensure coverage is confirmed prior to patient arrival or treatment.
• Demonstrate proficiency in payer portals and maintain expert-level knowledge of insurance guidelines, including network status, therapy coverage rules, and Medicaid-specific regulations.
• Accurately identify patient financial responsibility to reduce days in Accounts Receivable (AR) and improve upfront collections.

Financial Accuracy & Patient Responsibility

• Perform financial functions with precision, including copay collection and payment agreement creation under the No Surprise Act.
• Assign discount templates in accordance with GSPP guidelines to ensure equitable and compliant billing practices.
• Educate patients on financial obligations and assist in establishing private pay arrangements when necessary.

Authorization Management

• Manage the full authorization lifecycle—from submission to follow-up—ensuring timely approvals and accurate EMR documentation to prevent overutilization.
• Maintain and monitor authorization dashboards to ensure compliance and timely intervention.

Denial Prevention & Resolution

• Investigate and resolve insurance denials promptly, identifying root causes and implementing corrective actions to prevent recurrence.
• Collaborate with the Utilization Coordinator to analyze denial trends, submit appeals, and report findings for continuous process improvement.
• Achieve and maintain key performance indicators: denial rate below 5% and First Pass Resolution Rate of 95%.

Operational Excellence & Patient Experience

• Maintain assigned worklists to ensure patient records remain compliant and up-to-date.
• Deliver exceptional patient service through effective communication, service recovery techniques, and a positive demeanor.
• Lead or contribute to quality improvement initiatives that enhance operational workflows and patient satisfaction.
• Maintain a clean and organized work environment, including waiting areas, to support a welcoming atmosphere.

Administrative Support

• Greet and direct visitors professionally, ensuring a smooth and respectful experience.
• Assist patients in completing necessary documentation, including intake and insurance forms.
• Schedule, confirm, and manage patient appointments with accuracy and efficiency.
• Handle confidential medical records and correspondence with discretion and compliance.
• Manage inbound communications (calls, emails, faxes) and route appropriately to ensure timely response and resolution.

Essential Functions

Patient/Customer

• Ensures communication and collaboration with supervisors and fellow co-workers to serve patients and other customers to the best of his/her ability.
• Is professional in all actions and appearance
• Ensure compliance with regulatory parameters
• Uses resources wisely – as if they were one's own.
• Demonstrates understanding and ownership of how his/her role contributes to achieving the success of the Department and the Health System.
• Demonstrates a personal commitment to ensuring a clean and safe working environment.
• Anticipates patients'/customers' needs and acts accordingly.
• Works to enhance patient satisfaction
• Assist patients and families
• Analyzes problems from the customers' point of view.
• Honors patient/customer/employee confidentiality.
• Seeks feedback on how to improve performance and offers constructive feedback, as well.
• Applies learning for improved performance.
• Presents self professionally & demonstrates professional behavior during interactions with others
• Strives to understand and value differences in others' race, nationality, gender, age, background, experience, and style.
• Customer Service Skills
• Utilizes AIDET principles to enhance communication.

Patient/Employee Safety Accountabilities

• Patient Care Providers
• Participates in Entity and Department wide initiatives for Patient /Employee safety
• Demonstrates an awareness of patient/employee safety when carrying out daily responsibilities of their position.
• Validation of annual competencies required for the position

Operations

• Scheduling Functions
• Patient Identification
• Pre-Reg/Registration-Patient Information Updates
• Check-in Process
• Check-out Process
• Cash Collection
• Reconciliation and deposit.
• Insurance Verification Process
• Email
• Management of Medical Records
• Financial Counselor
• Department Productivity and goals (site specific)
• Site Opening Function
• Site Closing Function
• Ability to Multi-Task
• Understanding Clinical Work Processes
• Attendance/Time Management
• Involvement in Departmental Meetings
• Personal Impact
• Health System ID is worn in accordance with GSPP policy
• Ensures compliance with all federal and insurance laws

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education:

• High School Diploma required
• Associate's Degree preferred

Work Experience:

• 3+ years or equivalent as a Patient Service Representative 2
• Healthcare related experience required; billing experience preferred

Licenses / Certifications:

• N/A