Job Description
Job Description
Patient Care America is a premier renal healthcare provider specializing in precision medicine, nutrition support, and clinical solutions for kidney disease patients. We offer evidence-based therapies such as IDPN (Intradialytic Parenteral Nutrition) and IPN (Intraperitoneal Nutrition) to help manage malnutrition and improve clinical outcomes. Backed by published research demonstrating improvements in albumin levels, our therapies are trusted by nephrology teams and dialysis clinics nationwide.
Proudly accredited by PCAB, ACHC, and NABP, we uphold the highest standards of safety, quality, and care. But our commitment extends far beyond delivering infusion therapies; our value-added services include oral nutrition supplement programs, access to our clinical support nurse team, patient support networks, and free continuing education for registered dietitians and nurses.
As a leading renal solutions provider, we also offer bundled prescription medications, streamlining delivery and supporting improved medication adherence.
To support patients beyond the clinic, we provide digital tools and community-based platforms tailored to their needs and experiences. These tools include educational resources, the TransplantLyfe365 app, and an online peer community (www.TransplantLyfe.com) that helps patients connect with others and manage the everyday challenges of chronic kidney disease and transplantation.
Driven by a dedicated commitment to scientific rigor, clinical excellence, and compassionate care, Patient Care America is redefining what it means to be a true partner through each stage of kidney care.
BENEFITS
Our company offers:
- Competitive pay
- Monthly bonus program
- Generous paid time off
- Paid holidays
- Health insurance
- Life insurance
- Employer-paid Long-term and Short-term Disability
- Wellness
- 401 (k) retirement with company matching program
- Educational assistance
- Career growth
- and much, much more!!
You must be able to pass a drug, background screen, and be eligible to work in the U.S.
JOB SUMMARY:
The Insurance Specialist II is a member of the insurance team, responsible for managing complex insurance verification, prior authorizations, and appeals. This role involves working with a wide range of insurance plans, including major medical, PBM, Medicare B & D, and IPA claims. Specialist II provides guidance to Tier I staff, resolves escalated cases, ensures accurate billing and reimbursement, and collaborates with patients, healthcare providers, and payers to guarantee timely access to care.
QUALIFICATIONS:
- High School Diploma or GED required; Associate’s degree or two years of college education preferred.
- 3–5 years of experience in insurance verification, authorization, or similar healthcare roles (Home Infusion or Specialty Pharmacy preferred).
- At least 2 years of experience with prior authorizations, coordination of benefits, and patient assistance programs.
- Advanced knowledge of insurance plan designs, including major medical, PBM, Medicare B & D, IPA claims, and other complex benefits.
- Strong analytical and problem-solving skills to address escalated issues and ensure compliance with payer requirements.
- Proven ability to mentor or provide guidance to junior staff.
- Excellent customer service, verbal, and written communication skills with the ability to explain complex insurance policies clearly.
- Proficiency in standard office applications (Word, Excel, PowerPoint, Outlook) and industry-specific software (NewLeaf, CoverMyMeds, Navinet, payer portals).
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Verify and validate insurance benefits for patients, including copays, deductibles, coverage limits, and site-of-care eligibility, across complex payer plans.
- Manage complex authorization requests for pending and active patients, ensuring timely and accurate submission with required documentation.
- Collaborate with healthcare providers to gather clinical information necessary for authorization and appeal submissions.
- Handle escalated cases and resolve complex payer issues in collaboration with the Lead Insurance Specialist.
- Prepare and submit appeals for denied claims or coverage issues, ensuring completeness and compliance with payer requirements.
- Communicate authorization status, coverage details, and denials to patients, providers, and internal teams.
- Track, follow up, and escalate authorization and benefit issues to leadership when necessary.
- Mentor and provide guidance to Tier I Insurance Specialists, sharing best practices and payer-specific knowledge.
- Maintain accurate documentation in EMR and internal tracking systems, ensuring compliance and efficiency.
- Identify insurance trends, recurring denials, or process inefficiencies and propose solutions to improve departmental workflows.
- Provide backup coverage for Tier I staff during high-volume periods, PTO coverage, or staffing gaps.
- Participate in continuous education to stay current on CMS/Medicare Part B/D regulations, payer policies, and industry trends.
- Perform other duties as assigned to support departmental goals and the organization’s mission of delivering timely, high-quality patient care.