Chandler, Arizona, United States

Eligibility / Referral Representative

Posted over 1 month ago

Job Description

JOB OVERVIEW: Responsible for verifying and obtaining insurance benefits as required by insurance companies dependent upon the plan coverage for all patients. Works patient treatment schedules at least daily but in advance as time allows. Performs financial reviews and calculations based upon information received from the insurance company or plan, assists with logistical and/or clerical problem resolution related to the patients medical record, authorization and billing issues.

RESPONSIBLE TO: Supervisor or designee


- High School diploma or equivalent

- Two years experience working in a multi specialty group practice or healthcare system preferred.

- Two years patient third party eligibility verification experience on an automated patient accounts system preferred including 2 or more year's experience in insurance eligibility desirable.

- Two years experience with ICD-10, CPT, HCPCS codes.

- Understanding of clinic operations related to patient registration, referrals, authorization & cash collections.

- Intermediate to expert knowledge and computer skills including Windows programs and database applications preferred. Includes good keyboard skills 45+ wpm with high accuracy rate.

- Training or education in office and personnel management, computer/database systems and practice management systems.

- Understanding of insurance payer reimbursement, authorization, collection practices, practice management systems follow-up helpful.

- Ability to prioritize tasks and delegate duties.

- Strong leadership skills with attention to detail and accuracy.

- Ability to communicate effectively in written and spoken English.


- Demonstrates overall knowledge of authorization, benefits and claims processing for insurance companies and plans both private and government.

- Demonstrates the ability to make decisions, assess and resolve problems effectively.

- Demonstrates the ability to carry out assignments independently, work form procedures, and exercise good judgment.

- Demonstrates the ability to maintain the confidentiality of all records.

- Demonstrated ability to manage multiple tasks and demands given tight time constraints while ensuring a high degree of accuracy and attention to detail.

- Effective interpersonal skills in a diverse population.

- Ability to use a computer for extended periods of time.

- Proven effectiveness in verbal and written communication with the team, department and other

- Demonstrates overall knowledge of claims and authorization processing for insurance companies Including private, commercial and government carriers.

- Demonstrates overall knowledge of managed care plans.

- Demonstrates good mathematical skills

- Demonstrates effective communication and interpersonal skills with a diverse population.


- Must be able to sit and work at a computer for extended periods.

- Requires manual and finger dexterity and vision corrected to normal range.

- Requires effective communication with other staff and working under changing conditions depending on workload.

- Requires typing, legible penmanship and accurate data entry.

- Requires regular and punctual attendance.


Essential Responsibilities and Competencies:

- Researches and corrects invalid or incorrect patient demographic information such as invalid phone number or insurance policy number to ensure proper billing.

- Works closely with business office to ensure HCPCS codes, ICD10 codes, and procedure codes are accurate.

- Assists patients with questions or concerns regarding their account.

- Responds professionally to all inquiries from patients, staff, and payers in a timely manner. Usually within 24 hours.

- Keeps management informed of changes in authorization process, insurance policies, billing requirements, rejection or denial codes as they pertain to claim processing and coding.

- Accurately documents patient accounts of all actions taken.

- Establishes and maintains a professional relationship with all staff in order to resolve problems and increase knowledge of account management.

- Communicates with clinic management and staff regarding insurance carrier contractual and regulatory requirements.

- Educates clinic management and staff regarding changes to insurance and regulatory requirements.

- Informs management of any billing or authorization concerns, backlogs, insurance issues, problem accounts and time available for additional tasks.

- As necessary, negotiates a work improvement plan with management to raise work quality and quantity to standards.

- Attends appropriate workshops to enhance clerical, billing and computer skills.

- Completes additional projects and duties as assigned.

This description is a general statement of required major duties and responsibilities performed on a regular and continuous basis. It does not exclude other duties as assigned.


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