SPECIAL ACCOUNTS REPRESENTATIVE III

Insurance Specialist

Essential Functions

Follows up on open claims in accordance with established guidelines. Reviews claims for completeness and compliance with billing guidelines.

Works to resolution disputes and appeals of third-party denials. Contests charges that are not paid or underpaid with the carrier. Accesses available third party and governmental on-line services. Documents all actions within the system.

Possesses a comprehensive understanding of Clinic contracts, carrier specific, State or Federal governmental, HCFA, or CPT billing and reimbursement guidelines. Reviews bulletins, updates, etc., and maintains as reference/resource material.

Possesses a comprehensive understanding of how to enter insurance information into the billing system. Remain current on new FSC's that are created and understand how they are used. Reviews and edits registration information according to clinic policy.

Cross train in all areas within the Insurance Department. Assist Supervisor in the education of new employees, the monitoring of workflow in all areas of claims processing and payment posting within the Insurance Department.

Accesses available third-party and government on-line services. Accesses appropriate websites to obtain current carrier guidelines, verify eligibility and re-files claims if necessary.

Acts as liaison to the department to ensure any special projects and requests are completed efficiently and correctly. Acts as resource to peers.

Completes all appeals according to payer specific guidelines. Reviews clinical documentation for appeals and composes detailed formal appeal letters for payment.

Requirements

Required Education and Experience: High School graduate or equivalent. 3-6 years in a medical business office or related field. Experience with the claims adjudication process for multiple governmental agencies and private insurance carriers. Basic medical terminology. Current CPT and ICD-10 coding experience.

Additional Eligibility Qualifications: Ability to assist new hires and others in detailed training processes. An aptitude to retain detailed information. Ability to be multi-tasked oriented, to prioritize and to produce an acceptable volume of work. Excellent organizational and problem-solving skills. Excellent communication skills, oral and written. Basic knowledge of Windows-base computer applications. Accurate typing rate of 40 wpm. Ability to operate the following equipment: computer, copier, fax, web based payer sites, and 10-key calculator.