Insurance Agency Professional

The pay range for this position is listed below. Avera Downtown Building-Sioux Falls

Work Shift
Day Shift (United States of America)

Responsible for ensuring insurance eligibility, benefit verification, and the authorization processes are complete in the time allowed by the insurance companies to prevent denials or penalties. Specialists are responsible for documenting accurate insurance information and authorization details to optimize reimbursement from both the payer and patient. The Specialist must maintain strong working knowledge of insurance plans, contract requirements, and resources to facilitate appropriate insurance verification and authorization. Specialists must also be able to understand and interpret patient liability and benefits for all payer types including copays, co‑insurance, and out‑of‑pocket responsibilities in order to provide patients and families with information on their financial responsibility. The Specialist will calculate and communicate to the patient a financial responsibility estimation, provide charity applications and/or direct the patient to the business office for payment and assistance options. The Specialist collaborates with various other departments to ensure proper reimbursement on accounts. The Specialists are to conduct all transactions appropriately and consistently, and complete government regulatory forms accurately with the patient or patient's representative. EMTALA and HIPAA) as it pertains to the insurance process.

Process eligibility and secure full benefit coverage information (including COBRA when applicable) with insurance companies and employers, confirm all demographic information is correct, and ensure coordination of benefit (COB) and insurance plan codes are accurate. Specialists must verify insurance coverage immediately for inpatient and outpatient accounts that are same day and next day add-ons.

Identify all payment sources for accurate primary and secondary payer coverage and required authorizations to prevent denials and/or reduction in payment for patients entering the facility for care.

Obtain necessary paper/electronic referrals, authorizations and pre-certifications from Primary Care Physician and/or Specialty Physician when required by payers, Managed Care, and traditional Medicaid and enters information into the health information system.

Collects and validates accurate patient demographic and insurance information, verifies insurance, obtains pre-certification/authorization as required and enters all necessary information.

Calculate and communicate patient estimates for hospital services utilizing a deposit matrix or patient payment estimator to determine estimated patient responsibility and communicates financial expectations to the patient.

Identifies patients in need of financial assistance and provides charity applications and referrals to the business office as necessary.

Responsible to screen all self pay patients for potential payer coverage and directs applicable accounts to the advocacy team for further review. Provide communication concerning change of insurance coverage, prior to billing, from Registration staff and/or Patient Advocate/Billing staff.

Maintain professional development by attending workshops, in-services, and webinars to remain up-to-date on insurance rules and regulations in addition to changes within the industry.

To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions, as long as the accommodations do not cause undue hardship to the employer.

Required Education, License/Certification, Or Work Experience

1-3 years Related experience in billing, insurance or registration.

Preferred Education, License/Certification, Or Work Experience

Commitment to the daily application of Avera’s mission, vision, core values, and social principles to serve patients, their families, and our community.

Comply with safety principles, laws, regulations, and standards associated with, but not limited to, CMS, The Joint Commission, DHHS, and OSHA if applicable.

Avera is proud to offer a wide range of benefits to qualifying part-time and full-time employees. We support you with opportunities to help live balanced, healthy lives. Up to 5% employer matching contribution for retirement

Career development guided by hands-on training and mentorship

Avera is an Equal Opportunity Employer - Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, Veteran Status, or other categories protected by law. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call View phone number on click.appcast.io or send an email to View email address on click.appcast.io.