Insurance Verification Specialist

JOB TITLE: No Fault / PIP Insurance Verification Specialist III
EMPLOYER: Progressive Spine & Orthopaedics
PAY RANGE: OPM Pay Grade 6 (Hourly)
FSLA STATUS: Non-Exempt

SUMMARY: The No-Fault / PIP Insurance Verification Specialist III is a senior-level position responsible for independently managing complex No-Fault / PIP insurance verification, claim research, benefit determination, authorization requirements, and related documentation. This position serves as a subject-matter resource for the No-Fault / PIP verification team and is responsible for resolving complex coverage and claim issues that require advanced knowledge and follow-up.

The Specialist III works directly with insurance carriers, adjusters, attorneys, legal representatives, and internal departments to obtain and clarify complex claim information, resolve discrepancies, address exhausted or disputed benefits, and ensure appropriate documentation is maintained. The position also assists with training and mentoring lower-level specialists and escalates significant issues to management when appropriate.

ESSENTIAL DUTIES AND RESPONSIBILITIES

- Independently verify and research complex No-Fault / PIP claims, including claim status, claim numbers, dates of accident, adjuster information, benefit availability, benefit exhaustion, covered body parts, policy information, and applicable coverage limitations.
- Review and analyze PIP benefits, claim information, policy documentation, and supporting records to identify coverage issues, discrepancies, or potential barriers to reimbursement.
- Research and resolve complex insurance verification issues that cannot be resolved through standard verification procedures.
- Confirm policy, accident state, applicable coverage, policy limits, and payer requirements and determine how such information may affect patient services and billing.
- Independently research authorization and precertification requirements for applicable services, including office visits, procedures, radiology, surgery, and other treatment.
- Communicate directly with insurance carriers, adjusters, attorneys, and legal representatives to resolve complex claim and coverage issues and obtain necessary documentation.
- Request, review, and analyze supporting No-Fault documentation, including PIP ledgers, declaration pages, police reports, claim correspondence, attorney documentation, and other relevant records.
- Coordinate and monitor Letters of Protection (LOPs), including obtaining attorney confirmation, communicating with legal representatives, tracking outstanding documentation, and ensuring completed documentation is properly maintained in the patient record.
- Identify and investigate exhausted benefits, denied claims, disputed coverage, incorrect claim information, conflicting payer information, and other issues that may impact patient care or reimbursement.
- Maintain detailed and accurate documentation in the EHR, including verification notes, claim information, payer correspondence, authorization information, chart alerts, and supporting documentation.
- Monitor complex and outstanding verification matters and ensure appropriate follow-up is completed within established timeframes.
- Serve as a resource to No-Fault / PIP Insurance Verification Specialists I and II by providing guidance on verification procedures, documentation requirements, payer processes, and problem resolution.
- Assist with training and onboarding of new No-Fault / PIP staff and provide guidance on complex verification scenarios.
- Review work for accuracy and assist in identifying recurring errors, process gaps, or opportunities for improved efficiency.
- Assist management with identifying payer trends, recurring claim issues, and operational concerns affecting No-Fault / PIP collections and patient services.
- Escalate significant coverage disputes, compliance concerns, unusual claim circumstances, and unresolved issues to management or the appropriate department.
- Maintain strict confidentiality and comply with HIPAA, organizational policies, payer requirements, and established departmental procedures.
- Perform other related duties as assigned.

QUALIFICATIONS

- High school diploma or equivalent required; additional healthcare, insurance, or business education preferred.
- 3+ years of experience in No-Fault / PIP insurance verification, medical billing, automobile claims, insurance benefits, or a related healthcare administrative function preferred.
- Advanced working knowledge of No-Fault / PIP insurance verification, automobile claims, insurance benefits, authorization requirements, and healthcare documentation.
- Strong ability to research and resolve complex insurance and claim issues independently.
- Ability to interpret insurance information, PIP documentation, policy details, benefit limitations, and related claim documentation.
- Excellent verbal and written communication skills with the ability to communicate professionally with insurance carriers, adjusters, attorneys, patients, and internal departments.
- Strong organizational skills with the ability to manage multiple complex verification matters, deadlines, and follow-up requirements.
- Demonstrated ability to work independently while recognizing when issues require management escalation.
- Strong attention to detail and ability to identify inconsistencies or discrepancies in insurance and claim documentation.
- Proficiency with EHR systems and standard office software. ModMed and Microsoft - Excel experience preferred.
- Ability to maintain confidentiality and handle sensitive patient, insurance, and legal information appropriately.

CORE COMPETENCIES

- Advanced Insurance Knowledge
- Complex Problem-Solving
- Independent Judgment
- Accuracy & Attention to Detail
- Professional Communication
- Organization & Follow-Through
- Mentoring & Teamwork
- Confidentiality & Compliance

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 involve insurance verification, complex claims research, authorization review, documentation, and administrative follow-up performed within established organizational and payer guidelines. Although the position requires advanced knowledge and independent problem-solving, it does not consistently exercise discretion and independent judgment on matters of significance at the level 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 managements 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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