Insurance Authorization, Eligibility & Billing Specialist, Home Health

The Home Health Insurance Authorization, Eligibility & Billing Specialist is responsible for verifying insurance coverage, obtaining and managing prior authorizations, and supporting accurate billing for home health services, with a primary focus on Medicare, Medicaid and Medicare Advantage plans. This role works closely with intake, clinical, scheduling, and billing teams to ensure timely start of care, compliance with payer requirements, and appropriate reimbursement.

Key Responsibilities

Insurance Verification & Eligibility (Home Health)

• Verify patient eligibility, benefits, and coverage for home health services
• Confirm plan type (Traditional Medicare vs. Medicare Advantage) and identify delegated UM entities 
• Review benefits for visit limits, authorization requirements, and covered disciplines (SN, PT, OT, ST, HHA, MSW)
• Communicate eligibility findings and restrictions to clients, intake and clinical teams

Medicare Advantage Authorizations

• Obtain initial, ongoing, and recertification authorizations for Medicare Advantage patients
• Submit clinical documentation (OASIS, therapy evaluations, visit plans, physician orders) per payer guidelines
• Track authorization timelines and proactively follow up to prevent delays or interruptions in care
• Notify teams of approvals, partial approvals, denials, and changes to authorized visit counts

Billing & Claims Support (Home Health)

• Ensure authorization data aligns with scheduled visits and services rendered
• Review billing information for accuracy prior to claim submission
• Support timely claim submission to Medicare Advantage payers and delegated UM entities
• Assist with resolving claim denials, underpayments, and authorization-related billing issues

Compliance & Documentation

• Maintain accurate documentation in the EMR and billing systems to support compliant reimbursement
• Ensure adherence to Medicare Conditions of Participation and Medicare Advantage payer requirements
• Stay current on Medicare Advantage policies, authorization rules, and documentation standards

Communication & Collaboration

• Serve as a liaison between home health agency staff and insurance payers/UM vendors
• Collaborate with intake, case management, therapy, scheduling, and billing teams to ensure continuity of care
• Provide clear, timely communication regarding authorization status and payer requirements

Qualifications

Required

• High school diploma or equivalent
• 2+ years of experience in home health insurance verification, Medicare Advantage authorizations, or billing
• Strong knowledge of Medicare Advantage home health authorization processes
• Experience working with EMR systems and payer portals
• High attention to detail and strong organizational skills

Preferred

• Associate’s degree or certification in medical billing, coding, or healthcare administration
• Experience with home health EMRs 
• Familiarity with Medicare Advantage UM vendors and payer portals (e.g., Availity, Carelon, Essence, UHC, & Waystar)
• Understanding of OASIS, PDGM, iQIES, ICD-10, CPT, and HCPCS codes

Key Skills & Competencies

• Ability to manage high-volume Medicare Advantage authorizations
• Strong follow-up and time-management skills
• Problem-solving and denial resolution experience
• Ability to work independently in a fast-paced home health environment
• Excellent written and verbal communication skills

Performance Expectations

• Timely completion of eligibility verification and authorizations
• Accurate documentation supporting clean claims and reduced denials
• Consistent collaboration with clinical and billing teams