Insurance Accounts Receivable Specialist II

Insurance Accounts Receivable Specialist II

The Insurance Accounts Receivable Specialist II is responsible for managing more complex insurance claim follow-up and resolution activities. This includes working denials related to medical necessity, bundling, and non-covered services, as well as performing detailed account reviews to ensure accurate reimbursement. The role requires a strong understanding of payer guidelines, increased productivity expectations, and greater independence in resolving issues.

Essential Job Function/Competencies

The responsibilities and duties described in this job description are intended to provide a general overview of the position. Duties may vary depending on the specific needs of the affiliate or location you are working at and/or state requirements. Responsibilities include but are not limited to:

• Perform billing-related tasks as assigned, including data entry, claim review, charge review, and accounts receivable follow-up.
• Focus on resolving more complex insurance denials, such as those related to medical necessity, non-covered services, and bundling issues.
• Manage a higher volume and complexity of work compared to Level I, while maintaining accuracy and adherence to productivity expectations.
• Complete daily assignments in designated work queues following manager direction and established workflows.
• Utilize CBO Pathways, payer websites, billing systems, and training resources to determine appropriate actions for resolving unpaid or incorrectly paid claims and for authorizing procedures.
• Identify and escalate payer issues, provider credentialing discrepancies, or coding concerns to management as appropriate.
• Follow standard workflows provided during training and proactively seek additional training or clarification when needed.
• Review reports to identify unpaid claims and potential revenue opportunities.
• Adhere to department workflows, organizational policies, regulatory requirements, and FGP compliance and confidentiality standards.
• Communicate professionally with providers, patients, coders, and other stakeholders to ensure claims are processed correctly and efficiently by third-party payers.
• Provide feedback and recommendations related to system edits, billing processes, policies, and procedures to support revenue optimization.
• Attend required training sessions, participate in meetings and workgroups, and escalate issues to management as needed.
• Maintain patient confidentiality and apply policies and procedures to support informed decision-making and consistent operations.
• Collaborate effectively with team members and assist in explaining processes and procedures to others as needed.
• Make necessary system corrections and resubmit claims in accordance with payer requirements.
• Performs other position related duties as assigned.
• Employees shall adhere to high standards of ethical conduct and will comply with and assist in complying with all applicable laws and regulations. This will include and not be limited to following the Solaris Health Code of Conduct and all Solaris Health and Affiliated Practice policies and procedures; maintaining the confidentiality of patients' protected health information in compliance with the Health Insurance Portability and Accountability Act (HIPAA); immediately reporting any suspected concerns and/or violations to a supervisor and/or the Compliance Department; and the timely completion the Annual Compliance Training.

Certifications, Licenses or Registry Requirements

• N/A

Knowledge | Skills | Abilities

• Strong written and verbal communication skills with the ability to explain billing issues clearly.
• Working knowledge of insurance policies, denial types, and medical terminology.
• Ability to prioritize tasks, manage time effectively, and meet performance benchmarks.
• Demonstrated problem-solving skills and follow-through on account resolution.
• Skill in using computer programs and applications including Microsoft Office.

Education Requirements

• High school diploma or equivalent required.

Experience Requirements

• Previous experience in a customer service or healthcare setting preferred.

Required Travel

• N/A

Physical Demands

Carrying Weight Frequency

1-25 lbs. Frequent from 34% to 66%

26-50 lbs. Occasionally from 2% to 33%

Pushing/Pulling Frequency

1-25 lbs. Seldom, up to 2%

100 + lbs. Seldom, up to 2%

Lifting - Height, Weight Frequency

Floor to Chest, 1 -25 lbs. Occasional: from 2% to 33%

Floor to Chest, 26-50 lbs. Seldom: up to 2%

Floor to Waist, 1-25 lbs. Occasional: from 2% to 33%

Floor to Waist, 26-50 lbs. Seldom: up to 2%