Claims Verification Specialist for Workers Compensation and No Fault

The Claims Verification Specialist is responsible for verifying patient information, documentation, and insurance coverage for No-Fault (PIP), Workers’ Compensation, and lien cases. This includes ensuring all demographics and documents are accurate in the system, confirming claim details with insurance carriers, and maintaining direct communication with patients’ attorneys. The specialist plays a critical role in preventing delays, supporting billing compliance, and safeguarding reimbursement by maintaining accurate records and clear communication across all parties involved.

Detailed Responsibilities:

• Verify patient demographic information, identification, and all supporting documents in the system to ensure accuracy before claim processing.
• Confirm patient eligibility, benefits, accident details, claim numbers, and coverage status with insurance carriers, employers, attorneys, and third-party administrators.
• Communicate directly with patients’ attorneys to confirm representation, exchange required documentation, and resolve issues affecting claims.
• Ensure all required documentation is obtained at scheduling or intake, including ID, referrals, referring physician information, and attorney details.
• Maintain up-to-date claim records in the EHR/practice management system, including adjuster and attorney contact information.
• Coordinate with scheduling staff to resolve missing or incomplete information prior to patient visits.
• Notify billing staff promptly of any verification issues that may prevent claims from being billed within the required 7-day turnaround from Date of Service (DOS).
• Monitor ongoing claims to verify continued eligibility, resolve discrepancies, and follow up with carriers and attorneys as needed.
• Support billing compliance by ensuring coordination of benefits is properly identified and applied.
• Provide timely updates and escalate to management when verification or documentation issues affect claim submission.
• Maintain detailed documentation of all communications with carriers, attorneys, and internal staff for auditing and compliance purposes.
• Asist in reducing reporting backlogs by ensuring verifications are completed accurately and on time.
• Collaborate with scheduling, billing, and clinical teams to ensure smooth workflows across multiple facilities.
• Participate in audits, quality reviews, and reporting to strengthen processes and ensure compliance with regulations.

What the Candidate will bring:

• Understanding of NYS Workers Compensation/No Fault guidelines, terminologies, and processes. A minimum of 1 years of working in WC/NF experience required.
• Extremely detailed oriented, excellent problem-solving skills, and the ability to think critically.
• The ability to quickly think and make accurate decisions will determine the success of the candidate in this role.
• Strong communication skills with the ability to diagnose the cadence of any conversation.
• Ability to communicate effectively with a variety of personalities to achieve required results.
• Insurance and Claims Knowledge (No-Fault, Workers’ Compensation, liens).
• Documentation and Compliance Accuracy.
• Communication and Negotiation (carriers, attorneys, and internal staff).

Experience:

• Workers' compensation/No Fault: 1 year (Required)
• Customer service: 1 year (Required)

Work Location: In person