Medical Insurance Verification Specialist

Job Overview

The Medical Insurance Verification Specialist is responsible for completing the enrollment process for new Workers' Compensation patients by obtaining and verifying all information required to successfully bill the patient's initial prescription claim. This individual serves as the liaison between physician offices, injured workers, employers, insurance carriers, adjusters, nurse case managers, attorneys, and internal departments to ensure claims are set up accurately and efficiently.

This position plays a critical role in reducing billing delays, improving first-pass claim acceptance, and ensuring patients receive their medications as quickly as possible.

Position Objective

The Verification Specialist ensures every new Workers' Compensation patient is accurately enrolled and all required claim information is obtained before billing begins. By establishing complete and accurate patient records at the start of the process, this role helps reduce billing delays, improve reimbursement timelines, and support a positive experience for both patients and provider partners.

Essential Responsibilities
• Complete the enrollment of all new Workers' Compensation patients.
• Collect and verify all information required to establish a new Workers' Compensation claim.
• Contact insurance carriers, employers, adjusters, physician offices, nurse case managers, attorneys, and third-party administrators (TPAs) to obtain missing or incomplete claim information.
• Review documentation for completeness and accuracy before the claim is released for billing.
• Research and resolve missing enrollment information in a timely manner.
• Maintain detailed and accurate documentation within the pharmacy management system.
• Work collaboratively with Billing, Collections, Prior Authorization, Customer Service, Clinical, and Operations teams to ensure a seamless patient onboarding process.
• Identify and escalate complex enrollment issues that may delay claim processing.
• Maintain HIPAA compliance and protect confidential patient information.
• Meet established productivity, quality, and service expectations.

Qualifications
• High school diploma or equivalent required; associate or bachelor's degree preferred.
• Minimum of two years of experience in Workers' Compensation, medical billing, pharmacy, healthcare, or insurance.
• Working knowledge of Workers' Compensation claims and insurance processes.
• Experience communicating with insurance adjusters, TPAs, employers, and physician offices.
• Strong organizational skills with exceptional attention to detail.
• Excellent verbal and written communication skills.
• Ability to prioritize multiple tasks and work independently in a fast-paced environment.
• Proficient in Microsoft Office and healthcare software applications.

Preferred Experience
• Minimum (2) years Workers' Compensation pharmacy experience.
• Pharmacy revenue cycle experience.
• Insurance verification experience.
• Knowledge of medical terminology.
• Experience working within pharmacy or healthcare management systems.

Key Performance Indicators
• Average enrollment turnaround time
• Number of enrollments completed per day
• Enrollment accuracy rate
• Time to resolve incomplete or missing claim information
• First-pass billing readiness rate
• Documentation quality
• Productivity and quality standards
• Internal and external customer satisfaction