Verification and Eligibility Specialist

Austin - Atrium, TX
Full Time
Experienced

At Urology Austin, our mission is committed to improving the lives of patients and their families through compassionate, quality, and ethical care.

In choosing a career with Urology Austin, you are choosing to improve the lives of patients and their families through a collaborative team-driven approach in an innovative, quality-driven, community-based setting. Better Medicine. Better Care.

Position Summary:
The Verification & Eligibility Specialist is responsible for ensuring that all patients scheduled at Urology Austin have valid coverage and a clear understanding of their financial responsibility. This role is the "gatekeeper" of the revenue cycle, tasked with verifying benefits for a wide spectrum of urological services, including office visits, diagnostic imaging, biofeedback, and specialized procedures (e.g., Vasectomies, Cystoscopies, and Urolift). By confirming eligibility prior to the date of service, this specialist prevents claim denials and ensures a seamless experience for the patient.1
JOB RELATIONSHIPS
  • Reports to: Revenue Cycle Manager
  • Collaborates with: Front Office Coordinators, Authorization Specialists, and Surgical Schedulers.
ESSENTIAL JOB RESPONSIBILITIES
  • Comprehensive Benefit Verification: Verify active coverage for all new and returning patients via payer portals or phone. Confirm that the specific urological service is a "covered benefit" under the patient’s specific plan.
  • Urology-Specific Coverage Research: Determine coverage levels for diverse urological treatments.
  • Coordination of Benefits (COB): Identify primary, secondary, and tertiary payers. Ensure the correct order of billing to prevent "non-covered" denials due to COB errors.
  • Financial Liability Calculation: Accurately calculate and document the patient's estimated out-of-pocket costs, including:
    • Deductibles (Met vs. Unmet)
    • Co-insurance percentages
    • Fixed Co-pays
    • Out-of-pocket maximums
  • Referral Management: Monitor and obtain required Primary Care Physician (PCP) referrals for HMO and Managed Care plans to ensure the practice is "cleared" to see the patient.
  • EMR Documentation: Update patient records in Allscripts and Urochart with meticulous detail. Scan all benefit verification sheets and secondary insurance cards into the patient’s digital chart.
  • Provider Schedule Auditing: Review the upcoming clinic schedule (typically 3–5 days in advance) to resolve any eligibility "red flags" before the patient arrives.
ROLE QUALIFICATIONS
  • Education: High school diploma required.
  • Experience: 1–2 years of medical insurance verification experience. General Urology or Multi-specialty experience is highly preferred.
  • Technical Skills: Proficiency in EMR systems (Allscripts/Urochart). Expert navigation of payer websites (Availity, UnitedHealthcare, Medicare/Medicaid portals).2
  • Skills: Strong mathematical ability to calculate percentages and balances; excellent professional verbal and written communication.

PERFORMANCE REQUIREMENTS
Knowledge
  • Payer : Deep understanding of HMO, PPO, EPO, Medicare, and Texas Medicaid plans, including the specific nuances of commercial vs. government-funded insurance.
  • Urology Terminology: Familiarity with urological procedures and diagnoses to accurately communicate medical necessity to payers.
  • Regulatory Standards: Basic knowledge of HIPAA compliance and patient privacy laws regarding the disclosure of financial and medical information.
Skills
  • Payer Expertise: Demonstrated ability to navigate complex insurance portals and interpret electronic eligibility responses.
  • Communication: Ability to explain complex insurance terms and financial responsibilities to patients in a compassionate, easy-to-understand manner.
  • Multi-tasking: Proven skill in managing a high-volume daily schedule while maintaining 100% data entry accuracy.

Abilities
  • Analytical Thinking: Ability to spot "benefit gaps" or potential coordination of benefit (COB) issues before the patient arrives for their appointment.
  • Problem Solving: Ability to research and resolve eligibility discrepancies by contacting insurance representatives or patients directly.
  • Adaptability: Ability to manage multiple and changing priorities in a fast-paced  environment.

PHYSICAL DEMANDS AND WORK ENVIRONMENT
  • Physical: Involves sitting for approximately 80% of the day; extensive use of computer, mouse, and phone.
  • Environment: Professional office setting. Requires frequent interaction with patients and staff from various backgrounds.
  • Stress: Frequent stress from high-volume deadlines and the need to resolve insurance conflicts quickly to prevent appointment cancellations.
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