Insurance Specialist II

HOURLY RATE (DEPENDING ON SKILLS/EXPERIENCE): $21.00 - $27.43

SCOPE: Responsible for investigating aged insurance claims to determine appropriate action and provide resolution; by determining payment status using account notes, health plan websites and health plan customer service. Determines and facilitates appropriate action for claim resolution and correct financial responsibility via DOFRs, IPA and health plan contacts. Maintaining timely follow-up to ensure claims are corrected/rebilled/appealed within carrier filing limits. Effectively uses detailed documentation in EPM system(s) of all activities undertaken. Help to identify aged claim patterns to identify potential process improvements. Ability to multi-task and comfortable changing priorities as needed. Strong MS Office capabilities, including but not limited to Word, Excel and Outlook. Demonstrated ability to work well in a team environment. Assists in mentoring department personnel, assisting with questions/clarifications.

RESPONSIBILITIES:

• Multi-Specialty Billing experience required
• Maintains timely follow-up on outstanding insurance claims in appropriate EPIC WQs, ensuring claims are billed/rebilled within carrier filing limits
• Effectively takes appropriate action on claim denials to ensure prompt resolution and follows-up on those rebilled, corrected and appealed
• Maintains detailed documentation in software system(s) of all claims & collections activities, including rebills, all follow-up, and related correspondence with carriers, practitioners
• Call healthcare insurance companies, their affiliates & providers to resolve any question about contract or payment issues
• Informs Supervisor of problems related to insurance company payments/denials, contract pricing, and works with Supervisor and all parties involved to ensure prompt resolution
• Strong MS Office capabilities to include Word, Excel and Outlook
• Demonstrated ability to work well in a team environment
• Ability to multi-task in a fast-paced work setting
• Meet or exceed production, quality and accuracy standards while ensuring privacy and documentation procedures are maintained
• Meets or exceeds monthly A/R targets
• Work collaboratively with leadership and other team members to improve or challenge processes, provide trending and solutions insights and support the capability development of the team
• Investigate all insurance payments that deviate from expected payment (ie: underpayments, contracting issues)
• Assist in mentoring unit personnel, training, or re-training staff and assisting with onboarding of new personnel.
• May be required to attend conference calls when necessary.
• Will be responsible for maintaining spreadsheets assigned by Supervisor

MINIMUM QUALIFICATIONS:

• High School diploma or equivalent required
• 2 Years - Business Admin / Healthcare / Related Field preferred
• Certified Medical Reimbursement Specialist CMRS preferred
• Certified Medical Insurance Specialist CMIS preferred
• 3 years Billing in Medical Office / Hospital required
• 3 years CPT/ICD-10 guidelines and use of modifiers required
• 1 year Excel and other Microsoft office applications required
• 1 year EMR required
• 2 years EPIC EMR preferred
• 2 years Division of Financial Responsibility (DoFR) experience preferred

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations will be offered to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit and use hands to manipulate a computer keyboard and mouse. The employee is occasionally required to stand, walk, and reach with hands and arms. The employee must occasionally lift and/or move up to 30 pounds. Requires vision and hearing corrected to normal ranges.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations will be offered to enable individuals with disabilities to perform the essential functions. Work is performed in an office environment. Involves frequent contact with staff. While performing the duties of this job, the employee is regularly exposed to direct contact with patients with potential for exposure to blood, toxic substances, ionizing radiation and other conditions common to a clinic environment.