Insurance Specialist (Administrative)

JOB SUMMARY: The primary responsibilities of the Insurance Specialist are: ensure that payments received from the insurance companies are posted correctly to the patient accounts; ensure that denials and unpaid or partially paid claims are thoroughly researched; to provide specialized assistance to our patients and clinical staff using their knowledge base of a particular insurance; to provide excellent patient service.

SPECIFIC JOB DUTIES AND RESPONSIBILITIES:

Posting insurance payments using established procedures.
Contacting insurance companies when necessary to follow up on denials, unpaid or partially paid claims, to pre-certify services or other issues as they arise and documenting on the patient account per established policies.
Contacting patients when necessary to obtain current insurance information and ensuring that the information is correctly entered into their account, documenting on the account per established policies.
Following up on unpaid claims through the Billing System.
Taking phone calls from customers (Patients/guarantors, clinical staff, payors etc.) and answering questions about their accounts while maintaining HIPAA guidelines.
Contacting clinical staff and/or patients when necessary to obtain information needed in order to resolve an issue on an account.
Requesting correct/updated insurance information from patients so that charges may be billed to the correct insurance company, and following up to ensure that : the information was received and correctly entered on the account; the incorrect charges were refunded if already paid and generate corrected claim forms to the correct insurance company; the charges were paid.
Discussing with the Business Services Manager those charges that need to be written off due to timely filing and other issues
Bringing reimbursement issues to the attention of the Business Services Manager
Change in reimbursement for a particular code
Denial for out-of-network
Bundling/unbundling of CPT codes
Denial of services that should have, and normally would have, been paid
Decrease in volume and/or dollar amounts of remits
Partially paid claims
Notifying the Patient Service Department when payments are received for bad debt balances.
Ensure compliance with regulatory standards.
Adhere to Administrative and departmental policies.

EDUCATION, CERTIFICATION, LICENSURE, REGISTRATION: High School Diploma or equivalent

EXPERIENCE, KNOWLEDGE, SKILLS and ABILITIES:

Minimum of two years of medical office billing experience
Knowledge of clinic policies and procedures
Knowledge of medical terminology and insurance practices
Knowledge of computer programs and applications
Knowledge of grammar, spelling, and punctuation to type correspondence
Skilled in gathering, interpreting, and reporting insurance information
Skilled in trouble-shooting insurance problems and claims
Ability to identify claim problems and recommend solutions
Ability to sort and file insurance forms and associated information

REASONING ABILITY:

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
Ability to interpret a variety of instructions furnished in written, oral, or schedule form.

INTERPERSONAL SKILLS:

Must interact and communicate both verbally and in written form.
Must interact and exchange information regarding patients with physicians and other departmental personnel, and outside agencies on a frequent basis while respecting the confidentiality of patient information.

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.
While performing the duties of this job, the employee is regularly required to talk or hear.
The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
Specific vision abilities required by this job include close vision and the ability to adjust focus.

WORK ENVIRONMENT:
The work environment described here are representative of those an employee encounters while performing the essential functions of this job. This position involves potential exposure to infectious diseases. Colleagues are offered appropriate vaccinations and safety training.

COMMENTS:
This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of the job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job.