WHAT DOES AN INSURANCE VERIFICATION SPECIALIST DO?

Published: Sep 30, 2025 - The Insurance Verification Specialist verifies patient insurance benefits by contacting insurance companies, interpreting managed care contracts, and determining pre-certification requirements. This role involves calculating co-pays, determining patient financial responsibility, entering insurance and billing information into the accounting system, and ensuring accurate documentation is prepared and delivered to the appropriate staff. The specialist also communicates with patients regarding payments prior to surgery and assists with financial arrangements such as Care Credit.

A Review of Professional Skills and Functions for Insurance Verification Specialist

1. Insurance Verification Specialist Essential Functions

  • Insurance Verification: Responsible for verifying patient insurance coverage.
  • Medical Supply Coverage: Ensure necessary medical supplies are covered by an individual's medical insurance.
  • Authorization Processing: Conduct pre-authorizations or recertifications as required by insurance companies.
  • Policy Knowledge: Work with insurance companies and have extensive knowledge of different types of coverage and policies.
  • Record Maintenance: Maintain accurate patient insurance records.
  • Time Management: Focus and work quickly, as insurance paperwork commonly needs to be processed in a timely manner.
  • Team Collaboration: Work well with others, as he/she work as part of a healthcare team.
  • Data Entry: Responsible for entering data in an accurate manner.
  • Issue Resolution: Ensure insurance coverage by telephone, resolve any issues with coverage, and escalate complicated issues to a supervisor or manager.

2. Insurance Verification Specialist Additional Details

  • Case Review: Responsible for reviewing patients’ cases and insurance coverage information to personalize the call contents to the patient.
  • Record Management: Review patients’ scanned requisition records and input all information relating to insurance coverage.
  • Data Verification: Take and verify all patients’ demographic information when registering them for the service or program.
  • Information Accuracy: Identify important patient and demographic information that is missing and inform the client about it to avoid claim processing issues with the insurer.
  • Physician Communication: Establish contact with the ordering physician’s office or customer service department.
  • Issue Resolution: Resolve issues concerning missing vital information from patients' scanned requisition records.
  • Benefit Processing: Ensure timely processing of benefit information and seek assistance from management.
  • Team Collaboration: Work cordially in a team and participate in meetings, sharing ideas and information.
  • File Management: Ensure all inpatient files are available for daily verification of insurance benefits by printing the census.
  • Discharge Processing: Remove and forward discharged patients’ files to the Business Office.
  • Medicare Verification: Perform verification of Medicare coverage and limits on all Medicare accounts of patients.
  • Clinical Coordination: Contact clinical staff for the patient’s clinical information if it is needed by the insurance provider for the surgery to be certified.

3. Insurance Verification Specialist Roles

  • Insurance Verification: Contact insurance companies to verify patient benefits and complete insurance verification.
  • Billing Resolution: Review reports, research, and work with patients and other departments to resolve billing errors.
  • Account Review: Review insurance information in patient accounts and make necessary corrections.
  • Referral Coordination: Contact the referring physician's office to obtain a patient referral before the patient's visit.
  • Clinical Communication: Contact internal and external clinical staff for clarification on patient diagnosis, missing information, or to obtain a specialist’s referral prior to the patient’s office visit.
  • Request Management: Complete physician office requests with accuracy and urgency.
  • Task Handling: Handle both internal and external requests with accuracy and a sense of urgency.
  • Customer Communication: Communicate effectively and professionally with all customers.
  • Confidentiality Compliance: Adhere to confidentiality, state, federal, and HIPAA laws and guidelines with regard to patient records.

4. Insurance Verification Specialist Duties

  • Confidentiality Compliance: Protect confidential patient health information (PHI) at all stages of the verification of benefits process.
  • Benefit Verification: Perform detailed verifications of benefits for patients seeking treatment with Kerecis products.
  • Authorization Research: Obtain patient responsibility, research payer coverage criteria, and any required prior authorization requirements.
  • Task Management: Track tasks, review reports for accuracy and completeness, prepare and send insurance benefit verification results to healthcare providers on deadline.
  • Issue Resolution: Report and resolve any payer delays, challenges, and/or escalated complaints.
  • Team Collaboration: Collaborate with Market Access and Reimbursement teams.
  • Relationship Building: Develop productive working relationships with the U.S.
  • Provider Support: Coordinate support to healthcare providers and patients.

5. Insurance Verification Specialist Details

  • Eligibility Verification: Complete daily eligibility and benefit verification for all facilities utilizing best practice processes.
  • Account Documentation: Document benefits on the patient account for use by other team members.
  • Billing Preparation: Responsible for preparing accounts for billing.
  • Claim Review: Review and correct all claim rejections regarding eligibility.
  • Report Analysis: Review exception and discharge not final bill reports for outstanding MVA and WC information.
  • Insurance Verification: Complete verification of insurance as patients provide updates to Customer Service or via mail.
  • Error Resolution: Follow up and investigate any billing errors returned from payers.
  • Team Coordination: Work with respective team members/supervisors for resolution.
  • Data Update: Review and update demographic, guarantor, and insurance data obtained in the registration process.

6. Insurance Verification Specialist Responsibilities

  • Service Requests: Assist with processing all requests for services.
  • Referral Completion: Assist in the accurate completion of the referral form with medical and demographic information.
  • Referral Distribution: Assist with the distribution of referrals for assignment, scheduling, and billing.
  • Information Support: Assist in disseminating information and answering inquiries related to the availability of resources.
  • Medicare Verification: Verify Medicare benefits on patients and follow up on Beneficiary-Elected Transfers.
  • Team Collaboration: Demonstrate teamwork and effective communication to accomplish Agency and client goals.
  • Meeting Participation: Participate in other team/Agency meetings.
  • Resource Access: Work with the Intake team to identify and access outside resources.

7. Insurance Verification Specialist Roles and Responsibilities

  • Policy Compliance: Perform job in compliance with Agency policies and procedures and industry standards.
  • Department Support: Accept responsibility as an assistant to the Intake department and report to the Intake Manager.
  • Confidentiality Compliance: Maintain confidentiality in all aspects of the job up to and including HIPAA privacy laws.
  • Intake Assistance: Assist in the daily tasks of intake.
  • Report Management: Run and work various reports, i.e., Reauthorization Due, Unverified Insurance.
  • Call Handling: Answer phone calls and direct calls to appropriate office personnel.
  • Client Relations: Maintain friendly, cordial relations with all clients and employees.
  • Workplace Communication: Maintain a positive work atmosphere by acting and communicating in a manner that results in a positive work relationship with customers, co-workers, and managers.

8. Eligibility and Insurance Verification Specialist Duties and Roles

  • Admission Review: Review all admissions to ensure Medicaid, Medicare, and private insurance benefits are verified and appropriately documented within CBI’s electronic medical record (EMR).
  • Data Entry: Ensure accurate, complete, and timely capture and data entry of patients’ demographic, financial, and clinical information into CBI’s EMR system.
  • Benefit Verification: Verify all private insurance benefits, including deductible, co-pay amounts, and out-of-pocket cost for services rendered.
  • Financial Agreements: Develop financial agreements based on available benefits.
  • Process Coordination: Coordinate information from the patient, clinical staff, and front office staff to complete the verification process.
  • Quality Assurance: Work within a high-volume environment with an emphasis on quality assurance, patient/participants, with resources to assist with payments.
  • Payer Resolution: Identify and resolve issues related to incorrect payer assignment.
  • Billing Coordination: Work closely with the billing department to address issues identified.
  • Application Assistance: Responsible for meeting with patients/participants and assisting with the completion of AHCCCS applications.
  • Follow-Up: Follow through with applicants to obtain accurate and complete information within strict timeframes.

9. Insurance Verification Specialist Responsibilities and Key Tasks

  • Benefit Verification: Verify patient insurance benefits by contacting insurance companies and interpreting managed care contracts.
  • Pre-Certification: Determine pre-certification requirements.
  • Contract Review: Verify insurance benefits by reviewing the contract and the patient’s quoted benefits.
  • Co-Pay Determination: Responsible for determining co-pay.
  • Billing Documentation: Post all insurance and billing comments.
  • Data Entry: Enter all information into the patient accounting system.
  • Patient Communication: Contact patients regarding money due prior to the date of surgery.
  • Credit Assistance: Assist patients with credit agreements (Care Credit).
  • Payment Responsibility: Determine patient responsibility for cash payment based on reimbursement and account reviews.
  • Record Review: Review financial records for correctness.
  • Document Management: Attach the correct documentation to the verification sheets and deliver to the appropriate staff.

10. Lead Insurance Verification Specialist Roles and Details

  • PAU Specialist Duties: Perform all the duties of a PAU Specialist/Insurance Verifier.
  • Team Support: Assist with team member questions and the resolution of issues to provide optimal service delivery.
  • Staff Guidance: Provide guidance and support to the assigned team.
  • Training Delivery: Provide introductory and ongoing training and education to team members.
  • Process Monitoring: Monitor systems, processes, and procedures.
  • Standards Compliance: Ensure departmental standards are consistently met and identify improvement opportunities.
  • Task Organization: Organize daily assignments to ensure service standards are met.
  • Manager Collaboration: Collaborate with the manager to effectively communicate.
  • Process Improvement: Resolve issues, set and prioritize goals, improve processes, and implement changes.
  • Reporting Oversight: Assist with departmental reporting and account review to ensure departmental standards are met and sustained.
  • Team Communication: Assist with team member communication related to facility updates, goals, and process changes.

11. Insurance Verification Specialist Key Accountabilities

  • Data Entry: Responsible for data entry.
  • Phone Communication: Speak on the phone in a professional and courteous manner.
  • Verification Processing: Complete upwards of 20 verifications per day.
  • Workload Coordination: Coordinate workload with members of other departments.
  • Insurance Liaison: Serve as a point of contact for insurance-related questions within and between departments.
  • Cost Communication: Inform clients of out-of-pocket costs and follow up on out-of-pocket collections.
  • Department Support: Back up to other departments.
  • Relationship Management: Maintain positive relationships with referral sources, clients, coworkers, and providers.
  • Independent Work: Work independently and have the ability to meet deadlines.
  • Manager Reporting: Report to Office Manager/Executive Director.

12. Insurance Verification Specialist Job Summary

  • Eligibility Customization: Customize insurance benefit eligibility based on the services to be provided.
  • Service Identification: Identify eligible and ineligible services in a patient’s benefit package.
  • Patient Communication: Communicate directly with patients to discuss financial responsibility.
  • EMR Documentation: Document accurately and thoroughly in the EMR, SuccessEHS.
  • Claims Processing: Work directly with the insurance company, the patient, and clinic staff to get claims processed and paid.
  • Billing Support: Answer questions patients may have about billing.
  • Coverage Verification: Responsible for verifying patient insurance coverage.
  • Procedure Coverage: Ensure necessary procedures are covered by an individual’s provider.
  • Data Entry: Responsible for entering data in an accurate manner.
  • Benefit Updates: Update patient benefit information correctly in EMR and verify that existing information is accurate.
  • Change Notification: Notify patients if changes have occurred or need to be made regarding their insurance.
  • Pre-Visit Verification: Verify insurance prior to the visit.

13. Insurance Verification Specialist Accountabilities

  • Benefit Verification: Verify patient health insurance and benefit information and provide timely responses to patients and care coordination teams.
  • Insurance Verification: Verify insurance through web portals and by contacting insurance companies directly.
  • Coverage Assessment: Identify any potential non-coverage issues and effectively communicate across all departments and to patients.
  • Patient Communication: Communicate with patients to acquire necessary and pertinent information.
  • Precertification: Determine accurate insurance benefits and obtain precertification.
  • Follow-Up: Perform timely follow-up of new and existing precertification requests.
  • DME Verification: Verify the eligibility and benefits of patients referred to Rehab Medical for DME equipment.
  • Data Entry: Enter data in an accurate manner into the necessary system.
  • Guideline Awareness: Stay up to date on changing industry guidelines regarding insurance.
  • Team Communication: Communicate with the sales team and other departments for accuracy and clarity.

14. Insurance Verification Specialist Functions

  • Verification Audit: Check insurance verification of all consumers on a bimonthly basis.
  • Intake Benefits: Review and confirm benefits at intake.
  • Invoice Processing: Process invoices for consumer responsibility.
  • Invoice Follow-Up: Follow up on outstanding consumer invoices.
  • Payment Arrangements: Collaborate with families to set up payment arrangements.
  • Fee Schedule Management: Maintain fee schedules for all payers.
  • Controller Support: Perform additional reasonable tasks as requested by the Controller.
  • Coverage Verification: Verify insurance coverage for potential new patients and re-verify insurance coverage for existing patients.
  • Account Updates: Update patient electronic account data with corrected insurance information.
  • Service Coverage: Verify benefits and determine coverage for specific services.
  • Industry Updates: Maintain up-to-date information on various insurance companies and any relevant changes.
  • Staff Communication: Communicate important insurance data and updates to appropriate staff.

15. Insurance Verification Specialist Essential Functions

  • Benefit Verification: Perform verification of benefits and initiate prior authorization on referrals received from the Central Admissions Manager and/or Clinical Evaluators.
  • Portal Utilization: Utilize insurance portals to verify benefits and obtain authorizations.
  • Financial Documentation: Complete all necessary financial assessments and documentation, and upload to PointClickCare prior to admission.
  • Medicare Tracking: Call other nursing homes to check the days used for Medicare patients.
  • Pre-Admission Compliance: Ensure that the pre-admission paperwork is complete and required by National HealthCare’s policy.
  • Authorization Management: Obtain prior authorizations, gap exceptions, and referrals for outpatient PT, OT, and ST for all regions.
  • Patient Support: Serve as an intermediary between patients and outside sources related to questions or problems that patients may have regarding bills for services provided.
  • Payment Communication: Communicate payment policies to patients and finalize payment arrangements with the patient or guarantor.
  • Clinical Coordination: Facilitate all necessary communication between the clinical team and the referring providers.

16. Insurance Verification Specialist Role Purpose

  • Benefit Verification: Verify benefits for new and established patients.
  • Eligibility Check: Verify patient’s insurance eligibility and obtain detailed benefits for in-office surgical procedures.
  • Clinic Collaboration: Work closely with clinics to assist and build solid working relationships in a teamwork environment.
  • Network Confirmation: Confirm that insurance is in-network, then contact patients.
  • Arrangement Planning: Discuss and make alternate arrangements per policy guidelines.
  • Patient Communication: Communicate with the patient on their benefit information.
  • Coverage Verification: Verify the client’s benefits coverage and obtain a quote for services via online portals and calls to insurance companies.
  • System Documentation: Document benefit quotes and client communications in UB Intake System.
  • Information Sharing: Provide adequate communication to UB Therapists and clients regarding benefit information.
  • Team Collaboration: Work collaboratively to ensure appropriate coverage for all duties, including but not limited to other team members, the Assistant Intake Manager, and the Director.
  • Intake Operations: Intake and Insurance Operations.
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