Sr Insurance Specialist - Commercial/Blue Cross

Disclaimer for Job Postings

Note: The compensation range noted above represents the base salaries for all positions at a given grade across the health system. Typically, a new hire can expect a starting salary somewhere in the lower part of the range. Actual salaries will be determined based on the candidate's relevant experience. No employee will be paid below the minimum of the range.

Holyoke Medical Center is looking for a Sr Insurance Specialist. This position manages complex medical claims, acting as a subject matter expert to investigate, adjudicate negotiate settlements, ensure compliance and mentor junior staff, focusing on accurate and timely and cost-effective claims resolution while maintaining strong communication with providers, payers and internal teams. Works all claims as assigned/directed.

DUTIES AND RESPONSIBILITIES:
• Serve as subject matter expert, providing guidance on policy, regulations and complex claims scenarios.
• Conduct in-depth analysis, research discrepancies, prevent fraud and develop plans for claims resolution.
• Handles escalated inquires, build relationships with providers/payers and communicate claims status.
• Assist in training, coaching and provide senior support to less experienced team members.
• Review and process complex hospital claims and determine coverage based on policy, medical necessity and contracts.
• Able to work all aspects of Commercial Managed Care, Medicare Advantage, and Medicaid Advantage Care accounts sliding between Financial Classes as needed for Billing, Follow-up, Denials Management, Credit Balance and Account resolution.

Required Skills
• Must show honesty, integrity, strong ethics, data entry skills and time management skills
• Insurance follow up experience especially Blue Cross and all Commercial Lines
• Strong understanding of Medetech and finThrive billing programs
• Strong Verbal and written skills for preparing and presenting appeals, negotiating settlements and presenting reports to Senior Management.
• Proactive approach to resolving discrepancies between insurance policy terms and provider charges
• Ability to analyze complex data, identify issues and solve problems
• Proven background in handling complex institutional or healthcare related claims
• Proficiency with claims software and MS Office (especially Excel).
• Strong time management, organization skills and ability to work independently or in a team
• Good plus knowledge of ICS/HCPCS/CPT Coding and medical terminology
• Knowledge of commercial, state and federal healthcare regulations
• Excellent Math Skills and knowledge of general accounting principals
• Ability to logically and accurately organize data
• Excellent problem solving skills
• Strong attention to detail

QUALIFICATIONS/JOB REQUISITES:

Education: High School Diploma or GED is required, an Associate or Bachelor's degree in Health Administration or related Study preferred


Experience: Eight plus (8+) years in the health insurance, hospital business office or claims processing/management.