Job Title: 
Insurance Verification Representative

Major Medical | Personal Injury | Workers’ Compensation
Location: Clifton, NJ
Pay Range: OPM Pay Grade 6 (Hourly)
FLSA: Non-exempt

Position Summary:
The Insurance Verification Representative is responsible for verifying patient insurance coverage, benefits, eligibility, and claim details for major medical, personal injury, and workers’ compensation cases.

This role ensures that all insurance, attorney, claim, employer, and carrier information is accurate and properly documented prior to patient treatment or scheduled procedures.

The ideal candidate will have experience verifying commercial insurance benefits, out-of-network benefits, personal injury claim information, attorney representation, workers’ compensation claim status, and patient financial responsibility.

This position requires strong attention to detail, excellent communication skills, and the ability to work closely with patients, insurance carriers, attorneys, adjusters, employers, surgical coordinators, and billing teams.

Key Responsibilities
- Major Medical Insurance Verification
- Verify patient eligibility and active coverage for commercial, secondary, and tertiary insurance plans.
- Confirm out-of-network benefits.
- Review deductible, coinsurance, copay, out-of-pocket maximum, exclusions, and benefit limitations.
- Confirm whether the provider, facility, and services are covered under the patient’s plan.
- Identify coordination of benefits issues and request updated insurance information when needed.
- Obtain and document insurance representative names, call reference numbers, and verification details.
- Update patient accounts with accurate insurance benefit information.

Personal Injury Verification
- Verify personal injury case details, including date of accident, type of accident, claim status, and responsible party information.
- Obtain attorney information, representation letters, Letters of Protection, lien agreements, and claim documentation when applicable.
- Confirm auto insurance, third-party liability, med-pay, PIP, or bodily injury claim information when available.
- Communicate with attorneys, insurance adjusters, and patients to obtain missing or updated case information.
- Verify whether the case is open, active, settled, denied, or pending additional documentation.
- Document attorney contacts, claim numbers, adjuster information, payer details, and case status updates.
- Notify internal teams of missing attorney information, disputed liability, denied claims, or settlement concerns.

Workers’ Compensation Verification
- Verify workers’ compensation claim information prior to treatment or scheduled procedures.
- Confirm claim number, date of injury, employer, adjuster, carrier, and third-party administrator information.
- Verify claim status, approved body parts, authorized providers, and approved treatment.
- Confirm whether treatment, office visits, diagnostic testing, procedures, or surgery are approved under the workers’ compensation claim.
- Obtain adjuster authorization when required.
- Communicate with employers, adjusters, case managers, and workers’ compensation carriers to confirm coverage and claim details.
- Document all workers’ compensation verification activity, including contact names, phone numbers, authorization details, and claim status.
- Escalate denied, closed, disputed, or delayed workers’ compensation claims to management.

Surgical & Procedure Benefit Review
- Review scheduled surgical or procedure cases to ensure benefits and claim details are verified prior to the date of service.
- Confirm coverage for professional, facility, anesthesia, assistant surgeon, implant, and ancillary services when applicable.
- Verify benefit levels for in-network, out-of-network, personal injury, and workers’ compensation cases.
- Confirm deductible and out-of-pocket amounts met to date for major medical cases.
- Review benefit limitations or exclusions that may affect coverage.
- Notify surgical coordinators, billing teams, and management of any issues that may delay or affect scheduled services.

Patient Communication
- Contact patients to confirm insurance, accident, claim, employer, attorney, and demographic information.
- Explain insurance benefits, deductibles, coinsurance, copays, out-of-network benefits, claim status, and estimated patient responsibility in a clear and professional manner.
- Request updated insurance cards, attorney information, employer details, claim numbers, or supporting documentation when needed.
- Assist patients with insurance-related, personal injury, and workers’ compensation questions prior to treatment or surgery.
- Maintain professionalism and confidentiality when discussing patient insurance, legal, injury, and financial information.

Carrier, Attorney & Internal Communication
- Communicate with insurance carriers, attorneys, adjusters, employers, case managers, third-party administrators, and patients to verify coverage and case information.
- Use payer portals, phone calls, fax, email, and online verification tools to obtain accurate information.
- Work closely with surgical coordinators, billing staff, providers, front office teams, and management to ensure cases are financially reviewed.
- Follow up on incomplete, unclear, or missing insurance and claim information.
- Escalate complex verification issues, denied claims, inactive coverage, disputed liability, or authorization concerns to management.

Documentation & Reporting
- Maintain detailed notes of all verification activity.
- Document benefits, claim numbers, reference numbers, payer responses, attorney details, adjuster contacts, patient responsibility, and coverage concerns.
- Track pending verifications to ensure completion before treatment or scheduled surgery.
- Generate reports on pending verifications, missing insurance information, inactive policies, disputed claims, and cases not financially cleared.
- Ensure all documentation follows company policies, HIPAA guidelines, and applicable payer requirements.

Required Skills & Qualifications
Experience:
- 2–5 years of medical insurance verification experience required.
- Experience verifying major medical, personal injury, and workers’ compensation cases strongly preferred.
- Prior surgical or specialty practice verification experience preferred.
- Experience with Neuro Spine, Orthopedic, Pain Management, Podiatry, or surgical specialties preferred.
- Strong understanding of commercial insurance, out-of-network benefits, deductibles, coinsurance, copays, out-of-pocket maximums, and coordination of benefits.
- Knowledge of personal injury case information, attorney representation, Letters of - Protection, liens, med-pay, PIP, bodily injury, and third-party liability claims preferred.
- Knowledge of workers’ compensation claim processes, adjusters, employers, TPAs, claim numbers, dates of injury, approved body parts, and authorized treatment preferred.
- Familiarity with CPT, ICD-10, HCPCS, and surgical procedure terminology preferred.

Technical Proficiency
- Experience using EHR, EMR, practice management, or billing software.
- Proficient with payer portals and online insurance verification tools.
- Proficient in Microsoft Outlook, Excel, fax systems, and basic reporting tools.
- Ability to enter accurate account notes and maintain organized documentation.
- Knowledge of HIPAA compliance and patient privacy standards.

Communication Skills
- Excellent written and verbal communication skills.
- Ability to communicate professionally with patients, insurance carriers, attorneys, adjusters, employers, providers, surgical coordinators, and internal teams.
- Strong customer service skills.
- Ability to explain insurance benefits, claim status, and patient responsibility clearly.
- Comfortable making high-volume outbound calls to insurance carriers, attorneys, adjusters, employers, and patients.

Problem-Solving
- Strong attention to detail and ability to identify insurance or claim discrepancies.
- Ability to prioritize urgent surgical, injury-related, or time-sensitive cases.
- Analytical approach to resolving insurance, claim, and coverage issues.
- Ability to manage multiple cases in a fast-paced environment.
- Ability to work independently and as part of a team.

Education
- High school diploma or equivalent required.
- Associate’s or Bachelor’s degree in Healthcare Administration, Business, Legal Studies, or related field preferred.
- Medical billing, coding, or insurance verification certification preferred but not required.

Work Environment
- Office-based position
- Standard working hours, Monday–Friday
- Occasional overtime may be required to meet verification deadlines.
- Fast-paced, detail-oriented environment.
- Collaborative team setting with opportunities for growth and advancement.

Preferred Candidate Profile
- Experienced in verifying major medical, personal injury, and workers’ compensation cases.
- Strong understanding of insurance benefits, claim details, attorney communication, and adjuster follow-up.
- Detail-oriented, organized, and proactive.
- Comfortable working with surgical, injury-related, and high-value accounts.
- Able to communicate clearly and professionally with patients, insurance carriers, attorneys, adjusters, employers, and internal teams.