1. Insurance Verification & Pre-Authorization
- Eligibility Checks: Verify patient insurance coverage, benefits, and co-pay requirements before appointments.
- Prior Authorization: Coordinate with physicians and insurance companies to obtain approvals for surgeries, diagnostic tests, and specialist referrals.
- Policy Interpretation: Explain complex insurance benefits, deductibles, and "out-of-network" implications to patients in plain language.
2. Claims Management & Billing
- Claim Submission: Review and submit claims
- Denial Management: Investigate rejected or denied claims, correct coding errors, and resubmit appeals to secure payment.
- Revenue Tracking: Monitor "Days in Accounts Receivable" (AR) to ensure the clinic maintains healthy cash flow.
3. Patient & Provider Liaison
- Financial Counseling: Assist patients in setting up payment plans for balances not covered by insurance.
- Clinical Collaboration: Work with doctors and nurses to ensure documentation supports the medical necessity required by insurers.
- Conflict Resolution: Act as a mediator when disputes arise between the insurance company and the patient regarding coverage.
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