The Insurance Authorization & Cost Estimate Specialist is responsible for collecting necessary insurance benefit and clinical information to properly authorization the ordered service with the patient’s insurance company. This includes steps to support insurance and benefit verification, pre-certification, and pre-authorization processes.

The specialist must have clinical knowledge of services so appropriate information can be communicated/given to the insurance company which will ensure the service is rendered in the correct level of care. Reimbursement for the service rendered is dependent upon the insurance benefit verification process and meeting the authorization requirements of the insurance company.

The specialist must also determine when the patient is under-insured so that additional funding sources can be evaluated and applied.

Once authorized, the specialist determines the cost for the service by applying the patient benefits / coverage information and estimate functionality accessible through IT applications. This process is essential to ensuring the patient understands their financial responsibilities for the service rendered. This is a very dynamic environment as insurance plans, benefits, and coverage structures change frequently and the turnaround is essential so that treatment is not delayed.

This individual will need expert knowledge of insurance plans, insurance regulations, and insurance benefit and coverages as they relate to the service rendered. Additionally, this team serves as a point of contact within the organizations for questions and issues as they relate to insurance plans and coverage information.

The duties and responsibilities this individual performs is solely dependent on the organization receiving reimbursement for the service rendered and ensuring the patients cost are clearly identified.