The Insurance Verification Specialist is responsible for confirming insurance eligibility, benefits, and prior authorization requirements for scheduled orthopedic and surgical cases at LOS Surgery Center. Working in the Business Office, this role contacts payers, documents coverage accurately in the system, estimates patient financial responsibility, and communicates that information clearly to patients and to the scheduling, clinical, and billing teams — before the date of service whenever possible.

Accuracy and follow-through in this role directly affect case readiness, patient satisfaction, claim denials, and revenue. The specialist is expected to work proactively on upcoming schedules, flag coverage problems early, and resolve them with enough time for the patient and the center to make informed decisions. 

Insurance verification and benefits

· Verify eligibility and benefits for all scheduled patients — including coverage status and effective dates, deductible, coinsurance, copay, out-of-pocket maximum, and in-network / out-of-network status — using payer portals, clearinghouse tools, and telephone verification.

· Confirm coverage for the specific procedure(s), diagnosis, provider, and facility (LOS Surgery Center) scheduled, not just general medical coverage.

· Verify primary, secondary, and tertiary coverage and correct coordination of benefits; identify workers' compensation, motor vehicle / third-party liability, and other special coverage situations and route them appropriately.

· Complete verification in advance of the date of service according to Business Office timelines, and re-verify coverage when a case is rescheduled, coverage changes, or a procedure is added or changed.

· Document every verification completely and accurately — date, time, payer representative or portal reference, reference / confirmation number, and benefits quoted — in the patient account / electronic health record (EHR) system.

Prior authorization and pre-certification

· Determine whether prior authorization, pre-certification, pre-determination, or referral is required for each scheduled case and obtain it before the date of service.

· Record authorization numbers, approved dates, units / visits, and expiration dates in the patient account, and alert scheduling and clinical leadership promptly if an authorization is denied, pending for peer-to-peer review, or at risk of not being in place in time for surgery.

Patient financial communication

· Prepare good-faith patient cost estimates based on verified benefits and contracted rates, and contact patients before surgery to explain their estimated financial responsibility in plain, respectful language.

· Discuss payment expectations, deposits, payment options, and payment arrangements according to LOS policy, and document the conversation and any agreement in the patient account.

· Answer patient questions about coverage and estimates, explain that estimates are based on benefits quoted by the payer and may change once the claim is processed, and refer clinical questions to the appropriate clinical team member.

Provide required notices and information related to financial responsibility and, where applicable, federal and state requirements such as the No Surprises Act good-faith estimate  process for uninsured / self-pay patients, as directed by the Administrator. 

Coordination, billing support, and follow-up

· Work the upcoming surgery schedule daily — coordinate with scheduling, registration, nursing leadership, and anesthesia / provider offices to resolve missing insurance information, expired coverage, and authorization gaps before they delay a case.

· Communicate coverage issues, self-pay cases, and cases that should be rescheduled or held for financial reasons to the Administrator / Business Office Manager promptly, following LOS policy — never making a clinical decision about a patient's care.

· Support registration and billing as needed: correct insurance and demographic errors, update payer information, and assist with eligibility-related claim denials by providing verification documentation and reference numbers.

· Maintain organized verification logs / work queues, meet daily and weekly completion targets, and help train or cover for other Business Office staff as assigned (scheduling, registration, or billing support during absences).

· Perform other Business Office duties as assigned by the Business Office Manager.

Compliance and Professional Expectations  

· Protect patient privacy and confidentiality at all times in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and LOS policy; access only the minimum information necessary to perform the job.

· Complete required LOS policy attestations (including Confidentiality, Compliance, and Data Security) electronically via Paylocity, and complete assigned compliance and healthcare training modules on time.

· Follow LOS policies and procedures and support AAAHC and Centers for Medicare & Medicaid Services (CMS) readiness — including accurate, timely documentation that can be verified from the record.

· Report suspected billing, coverage, or compliance concerns to Leadership promptly; do not alter, backdate, or misrepresent verification or authorization records.

· Represent LOS professionally with patients, payer representatives, physician offices, and coworkers.

Qualifications

· Cooperative work attitude toward co-employees, management, patients, visitors, and physicians

· Ability to make decisions and solve problems

Ability to promote favorable facility image with physicians, patients, insurance companies, and general public 

Education and Experience

· High school diploma or equivalent required.· Minimum 1–2 years of insurance verification, prior authorization, patient registration, medical billing, or related revenue-cycle experience in a healthcare setting preferred; ambulatory surgery center, orthopedic, or surgical practice experience is a plus.· Experience verifying commercial insurance, Medicare, Medicare Advantage, Medicaid / Medicaid managed care, workers' compensation, and TRICARE / VA coverage preferred.· Familiarity with CPT and ICD-10 coding as used in authorization and verification (coding certification not required for this role).

Knowledge, Skills, and Abilities

· Working knowledge of health insurance benefits, deductibles, coinsurance, copays, out-of-pocket maximums, coordination of benefits, and prior authorization requirements.· Proficiency with payer portals, eligibility / clearinghouse tools, and telephone verification with insurance companies; comfort working with multiple payers in a single day.· Strong computer skills — EHR / practice management system, Microsoft Office (Outlook, Word, Excel), and accurate, fast data entry. Experience with LOS systems will be trained on the job.· Excellent attention to detail and documentation: reference numbers, names, dates, and benefits quoted must be recorded completely every time.· Clear, professional, and compassionate communication with patients about money — including difficult conversations — while protecting privacy and treating every patient with respect.· Ability to prioritize a high-volume, deadline-driven workload tied to the surgery schedule, work independently, follow up persistently, and escalate problems early rather than letting them surface on the day of surgery. Reliability and discretion: regular, punctual attendance and strict handling of confidential patient and financial information.

Dependability

· Attendance

· Punctuality

· Ability to follow instructions

Ability to meet deadlines 

Physical and Mental Requirements 

This is primarily a sedentary, office-based role in the Business Office. The employee will:

· Sit for extended periods and work at a computer and telephone for most of the workday, with frequent speaking and listening on payer and patient calls.

· Use hands for typing, data entry, and handling paper files; occasionally stand, walk, reach, and lift or move files or office supplies up to 15 pounds.

· Work in a typical medical office environment with moderate noise; reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job.

Working Conditions 

· Well lit and   ventilated, with non-hazardous and hazardous equipment