Insurance Specialist II

Medical Insurance Claims Processor

Reviews Explanation of Benefits (EOB's), incoming reimbursements via electronic deposits or paper checks, and remittance advice received from payors to ensure accurate distribution and posting of payments to accounts. Audits to ensure that all required billing documents are available and correct. Performs account maintenance and follow-up on all denials and outstanding claims.

Qualification Requirements

Must be proficient in processing medical insurance claims. Knowledge of medical billing/collection practices and above average understanding of debits and credits are required. Basic medical coding and third-party operating procedures and practices is required.

Minimum Qualifications

• Three (3) years of related experience and AS or equivalent combination with a minimum of 2 years of medical insurance claims experience.
• Ability to read and interpret the most current CPT and ICD coding (preferred).
• Proficiency in Microsoft Office (Word, Outlook, Excel), including word processing and spreadsheets.
• Knowledge of applicable EHR, Practice Management, Allscripts PM, Clinical Module Medical Records, and Document Manager systems.
• Familiarity with CMS 1500 claim form completion.
• Passage of a criminal background check, OIG exclusion, and drug screenings.
• Reliable transportation.

Knowledge, Skills and Abilities

• Detail-Oriented: Excellent records maintenance skills and attention to detail.
• Effective Communication: Strong oral and written communication skills.
• Proactive and Independent: Self-starter with strong decision-making skills.
• Cooperative Work Environment: Ability to foster cooperation, accept direction, and perform repetitive tasks.
• Interpersonal Skills: Strong interpersonal skills for working with diverse constituencies.
• Healthcare Billing Knowledge: Understanding of healthcare billing procedures, documentation, and standards.
• Billing and Payment Cycles: Knowledge of billing and payment cycles for third party payor accounts.
• Evaluative Judgments: Ability to make evaluative judgments.
• Computer Skills: Proficiency in word processing, Outlook, and Excel.
• Multitasking and Organization: Ability to handle multiple tasks, concentrate on details, and organize resources.
• Third-Party Payor Knowledge: Understanding of operational characteristics and procedural requirements.
• Ethical Standards: Knowledge of ethical standards for follow-up of overdue accounts.
• Medical Records Analysis: Ability to analyze medical records and identify billable services.
• Credit and Collection Knowledge: Understanding of credit and collection principles, process regulations, and standards.

Supervisory Responsibilities:

None

Essential Functions

• Claim Management (75%)
• Process EOBs: Handle third party payor Explanation of Benefits (EOBs), including annotating accounts with relevant information.
• Reconcile Accounts: Identify and correct errors in patient accounts, including overpayments, and confer with the Billing and Reimbursement Supervisor on delinquent accounts.
• Adjustments and Recoupments: Submit adjustments for overpayments and post recoupments as they appear on remittance.
• Payment Distribution: Research and accurately distribute incoming payments and remittance advice.
• Follow-Up: Manage Follow-Up Work Queues for third party payors to ensure timely reimbursement, checking every 45 days.
• Handle Rejections: Address all issues related to third party payor rejections.
• Communication: Verify benefits by communicating with patients, guarantors, and insurance companies. (10%)
• Documentation: Maintain and organize master document files for verification and backup of data entered. (5%)
• Stay Updated: Regularly review and keep up-to-date with third party payor bulletins, guidelines, and requirements. (5%)
• Compliance and Safety: Follow safety policies, participate in safety training, adhere to billing requirements, and maintain confidentiality in line with HIPAA guidelines. (5%)

Physical Demands

• Frequently lift/move up to 10 pounds using provided tools (e.g., hand carts).
• Requires eyesight (corrected or uncorrected) to accurately read and record information.
• Data entry involves repetitive motion.
• Regularly required to stand, talk, and hear; occasionally sit, stoop, kneel, or crouch.
• Requires full range of body motion, manual dexterity, and eye-hand coordination.
• Significant phone use with hands-free headsets to prevent injuries.

Work Environment

Work Schedule is Monday- Friday, 8 am to 5 pm. Slight modifications may be made to this schedule with approval from the manager. Work is normally performed in a typical interior/office work environment. The noise level is usually moderate. Low risk of exposure to blood borne pathogens and OPIM. Must be able to work overtime hours as needed to accomplish the mission of the organization.

This position is designated as an on-site, patient-facing role. In-office presence is an essential function due to the need for real-time collaboration with providers, direct interaction with patients and caregivers, and secure handling of health data in compliance with HIPAA.