Patient Cost Estimate Specialist

About the role

The Patient Cost Estimate Specialist verifies health insurance eligibility and benefits using RTE tools. Proactively identifies and resolves insurance issues to reduce registration and check-in inefficiencies. Supports all departments, including multiple practices and/or markets, by ensuring accurate insurance package registration, including network status, provider participation, benefit interpretation, package registration, and referral requirements.

Key responsibilities

• Utilize real-time eligibility (RTE) tools to verify health plan coverage, accurate insurance package registration, and obtain benefit information including detailed benefits when applicable. If RTE is unavailable, verification steps will be conducted utilizing payer portals and payer contact centers via phone. A full, detailed benefit note will be added to the account.
• Communicate effectively with patients, providers, or internal teams to obtain missing information and ensure continuity of care and service.
• Ensure all insurance coverage and relevant benefits are accurately documented in the patient account.
• Maintain team work queues to ensure timely review and processing of all incoming insurance verification requests.
• Provide accurate TOS estimates based on verified benefits to communicate patient financial responsibility electronically, including copays, coinsurance, deductibles, and out-of-pocket costs.
• Proactively identify patients requiring referrals via worklists. Obtain required referrals and/or authorizations in accordance with payer requirements; follow up with patients, providers, and payer sources as needed.
• Collaborate with front office, clinical teams, and other partnering departments to verify correct package registration, confirm network status, and resolve coverage discrepancies ensuring timely resolutions for any account requested.
• Answer transferred patient phone calls through assigned ring group(s) in accordance with established participation standards to address insurance benefit inquiries.
• Utilize centralized communication platform for position resources, announcements, PTO planning, etc.
• Support the Contact Center during peak volume periods.

About you

• Bachelor's Degree in any field is REQUIRED

Two years of experience in prior authorization, pre-certification, or insurance verification in a physician office or hospital environment.

• Orthopedic experience strongly preferred.
• Strong knowledge of insurance authorization processes and payer requirements.
• Familiarity with CPT, ICD-10, and basic medical terminology (orthopedics preferred).
• Ability to interpret clinical documentation and payer medical necessity guidelines.
• Proficient with EHR systems, pre-certification platforms, and payer portals.
• Excellent communication, organization, and time-management skills.
• Ability to manage multiple requests in a fast-paced environment.
• Strong customer service and ability to communicate clearly and concisely in all written and oral communications, including email.