Pre-Verification Specialist

Pre-Verification Specialist / Charge Review Specialist

Position Summary

The Pre-Verification Specialist/Charge Review Specialist is responsible for ensuring accurate insurance verification, coverage validation, and claim readiness prior to and following patient visits. This role serves as a key resource for clinics regarding insurance-related questions and works closely with patients, insurance carriers, and internal departments to ensure accurate billing and reimbursement.

Essential Responsibilities

Pre-Verification Functions

• Verify patient insurance coverage for scheduled appointments at least four days prior to service dates.
• Review and process accounts that are not already in a verified status within the work queue (WQ).
• Contact patients and insurance carriers to obtain and confirm eligibility, benefits, and coverage information.
• Ensure the correct insurance plans are loaded in the patient account and make necessary corrections when discrepancies are identified.
• Serve as the assigned insurance resource for designated clinics, providing support and answering insurance-related questions.
• Document verification activities and updates accurately within the appropriate systems.

Charge Review Functions

• Review and resolve insurance-related errors that populate in the work queue after patient visits.
• Contact insurance carriers to verify active coverage and confirm accurate insurance information.
• Update patient accounts with correct insurance coverage and demographic information as needed.
• Correct claim filing orders to ensure claims are billed to the appropriate payer in the correct sequence.
• Communicate with patients to obtain updated insurance information when required.
• Collaborate with billing, clinic, and revenue cycle teams to resolve claim and coverage issues efficiently.
• Maintain compliance with organizational policies, payer requirements, and applicable regulations.

Required Skills and Qualifications

• Knowledge of health insurance verification, benefits, eligibility, and payer guidelines.
• Understanding of medical billing processes, claim filing procedures, and coordination of benefits.
• Strong attention to detail and problem-solving skills.
• Excellent verbal and written communication skills.
• Ability to work independently and manage multiple priorities in a fast-paced environment.
• Proficiency with electronic medical records (EMR), practice management systems, and work queues.
• Customer service experience and the ability to professionally interact with patients, providers, and insurance representatives.

Preferred Qualifications

• Experience in healthcare administration, patient access, insurance verification, medical billing, or revenue cycle management.
• Familiarity with Medicare, Medicaid, and commercial insurance plans.
• Knowledge of claim edits, denials management, and insurance filing requirements.

Key Competencies

• Accuracy and attention to detail
• Customer service
• Communication skills
• Time management
• Problem-solving
• Team collaboration
• Insurance and billing expertise