No Fault/PIP Insurance Verification Specialist Level I

JOB TITLE: No Fault / PIP Insurance Verification Specialist I
EMPLOYER: Progressive Spine & Orthopaedics
PAY RANGE: OPM Pay Grade 4 (Hourly)
FSLA STATUS: Non-Exempt

SUMMARY: The No-Fault / PIP Insurance Verification Specialist I is an entry-level position responsible for obtaining and documenting basic automobile insurance and PIP claim information prior to patient services. This position performs routine insurance verification tasks using established procedures and guidelines and assists with identifying missing or incomplete information.

The Specialist I communicates with insurance carriers and adjusters to obtain basic claim and benefit information, documents findings in the electronic health record, and escalates complex issues to a senior team member or supervisor. The role supports accurate patient information, timely care, and billing processes while maintaining confidentiality and compliance with established workflows.

ESSENTIAL DUTIES AND RESPONSIBILITIES
- Verify active No-Fault / PIP claims, including claim number, date of accident, adjuster information, benefit status or exhaustion, covered body parts, and other applicable coverage details.
- Confirm policy and accident state information, liability or policy limits when available, and payer billing or contact information needed to support patient care and billing.
- Determine whether precertification or prior authorization is required for applicable services, including office visits, radiology, and other ordered treatment, and document the appropriate payer contact information.
- Communicate with insurance carriers, adjusters, attorneys, and legal staff to clarify benefits, resolve missing information, and obtain required documentation.
- Request and review supporting No-Fault documentation as applicable, including PIP ledgers, police reports, declaration pages, and relevant medical records.
- Coordinate Letters of Protection (LOPs) when appropriate, including obtaining attorney confirmation, sending required requests, and ensuring completed documentation is added to the patient record.
- Maintain complete verification documentation in the EHR, including insurance notes, verification forms, task notes, appointment-related information, and patient chart alerts or sticky notes as applicable.
- Identify coverage discrepancies, exhausted benefits, missing documentation, or other barriers; escalate issues appropriately and follow HIPAA and established verification workflows.

QUALIFICATIONS
- High school diploma or equivalent required.
- Previous experience with insurance verification, automobile claims, medical benefits, or a related healthcare administrative function preferred; comparable administrative experience may be considered.
- Basic working knowledge of insurance eligibility, claim verification, authorization requirements, and healthcare documentation practices, with the ability to learn No-Fault / PIP workflows.
- Strong attention to detail and ability to review insurance, medical, and legal documentation for accuracy and completeness.
- Professional verbal and written communication skills and ability to manage assigned follow-up with adjusters, attorneys, patients, and internal staff.
- Ability to organize multiple verification requests and outstanding items
- Basic computer skills and proficiency with Microsoft Office.
- Experience with EHR systems, ModMed, or Microsoft Excel is a plus.
- Ability to maintain confidentiality when handling patients, insurance, and claim information.

CORE COMPETENCIES
- Accuracy and attention to detail • Organization and follow-through • Customer service • Communication • Ability to follow procedures • Basic problem-solving • Confidentiality • Teamwork • Willingness to learn

PHYSICAL DEMANDS AND WORK ENVIRONMENT
The position is primarily performed in a professional medical office environment. Work requires prolonged periods of sitting and computer use, with occasional standing, walking, bending, reaching, and movement throughout the office. Frequent use of a computer keyboard, mouse, telephone, scanner, and other standard office equipment is required. The position requires the ability to review and process detailed insurance, claims, medical, and legal documentation, maintain confidentiality, and communicate effectively by telephone, email, and electronic systems.

DOL / FLSA CLASSIFICATION AND JUSTIFICATION
This position is classified as Non-Exempt because its primary responsibilities consist of routine insurance verification, data entry, documentation, follow-up, and administrative support performed according to established procedures and guidelines. The position does not independently exercise the level of discretion and judgment on matters of significance required for the FLSA administrative exemption. The position is therefore eligible for overtime in accordance with applicable federal and state laws.

The above is intended to describe the general content of and requirements for the performance of this job. It is not to be construed as an exhaustive statement of duties, responsibilities, or physical requirements. Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

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