Sage Infusion is seeking an experienced Benefits Specialist Lead for its Revenue Cycle Management team. This full-time, salaried position is fully remote and available to candidates residing in Florida. The role involves conducting comprehensive medical insurance investigations, preparing patient cost estimates, identifying financial assistance, and resolving complex benefit issues. Candidates must have at least five years of direct medical benefits verification experience with commercial and government plans, alongside prior leadership experience. Experience in specialties such as infusion therapy, biologic medications, specialty pharmacy or oncology is preferred. This position reports to the Associate Director of Revenue Cycle Management and provides direct supervision and support to assigned team members.

Responsibilities

Benefits Verification

• Complete comprehensive medical insurance benefit investigations for new and existing patients.
• Verify active coverage, effective dates, plan type, network status, deductibles, copays, coinsurance, out-of-pocket maximums, accumulations, benefit limitations, and applicable exclusions.
• Verify benefits for commercial insurance, Medicare, Medicare Advantage, Medicaid, TRICARE, marketplace plans, secondary insurance, and other United States health insurance products.
• Determine the correct primary and secondary payer order and identify coordination-of-benefits issues.
• Review plan documents, payer portals, medical policies, and payer communications to confirm coverage requirements.
• Review applicable CPT, HCPCS, J-codes, ICD-10 codes, medication dosage, units, frequency, and place of service to identify coverage, authorization, medical-policy, and reimbursement requirements.
• Identify site-of-care restrictions, specialty-pharmacy requirements, and other payer-specific medication fulfillment requirements.
• Document all verification activity, payer communications, reference numbers, benefit details, and follow-up requirements accurately and promptly.

Patient Cost Estimates

• Prepare accurate patient cost estimates for assigned complex, urgent or escalated cases using verified benefits, current accumulations, anticipated treatment services, medication dosage, applicable codes and available reimbursement information.
• Update assigned estimates when coverage, accumulations, treatment plans, or payer requirements change.
• Investigate and correct discrepancies involving benefit information or estimated patient responsibility.
• Work closely with Lucent Pricing on Vivid Price tool, for completing timely and accurate cost estimates for all appointments. 

Patient and Internal Communication

• Communicate directly with patients regarding insurance coverage, estimated financial responsibility, financial assistance options and unresolved benefit issues in a clear, professional, and compassionate manner.
• Respond promptly to questions and requests from Intake, Prior Authorization, Claims, Clinical, and Revenue Cycle teams.
• Escalate unresolved, high-risk or unusual cases to Revenue Cycle leadership when appropriate.

Financial Assistance

• Utilize GetCoPayHelp to enroll eligible patients in manufacturer copay assistance, patient assistance and foundation programs.
• Monitor enrollment status, funding, renewal, funding availability and communication with patients and internal teams.
• Communicate program outcomes and patient responsibilities to patients and applicable internal teams.

Payer and Cross-Functional Coordination

• Determine whether prior authorization, predetermination, referral, medical-necessity review or another payer approval is required.
• Investigate discrepancies between verified benefits and authorization outcomes.
• Initiate, negotiate and coordinate Single Case Agreements with out-of-network payers when needed.
• Communicate with payer representatives regarding reimbursement terms, covered services, effective dates, authorization requirements, and agreement conditions.
• Investigate claim issues directly tied to inaccurate or incomplete benefit information and collaborate with the Claims team to identify the source of the issue.
• Provide benefit documentation and payer references and verification records as needed.

Process Improvement and Enterprise Collaboration

• Follow established Sage workflows, documentation standards, and escalation procedures.
• Identify workflow gaps, recurring errors, inefficiencies and opportunities for improvement.
• Recommend process changes to the Associate Director of Revenue Cycle Management.
• Obtain approval from Revenue Cycle leadership before implementing material workflow or policy changes.
• Develop standardized benefits workflows across Sage Infusion, Sage Elevate, MemoryWorkx, Eversense, and other applicable Sage entities and pilots.
• Collaborate with Intake, Prior Authorization, Claims, Clinical, Lucent Pricing and Revenue Cycle teams to improve accuracy and operational consistency.
• Develop training materials, and reference resources.

Required Qualifications

• Associate/bachelor’s degree or equivalent experience.
• At least five years of direct medical insurance benefits verification experience.
• Extensive knowledge of US medical insurance plans, including commercial insurance, Medicare, Medicare Advantage, Medicaid, TRICARE, marketplace plans, and secondary coverage, and associated payer portals, such as Availity.
• Demonstrated ability to independently complete complex medical benefit investigations, and resolve payer discrepancies.
• Experience communicating directly with patients regarding coverage and financial responsibility.
• Experience interpreting deductibles, copays, coinsurance, out-of-pocket maximums, accumulations, network status, and coordination of benefits.
• Working knowledge of CPT, HCPCS, J-codes, ICD-10 codes, medical policies, prior authorization requirements, and place-of-service requirements.
• Previous leadership, team-lead, training, mentoring, or supervisory experience.
• Ability to manage competing priorities and work independently in a remote environment.

Preferred Qualifications

• Experience with infusion therapy, provider-administered medications, biologics, oncology, immunotherapy, or specialty pharmacy.
• Experience negotiating Single Case Agreements.
• Experience developing benefits workflows, standard operating procedures, or training materials.
• Experience conducting quality audits or monitoring team performance.