Insurance Claim Specialist

Insurance Claim Specialist

Works under the supervision of the Assistant Manager of Claims Management and Lead Insurance Claim Specialists. The Insurance Claim Specialist's primary job functions is to analyze, process, submit, and follow up on inpatient and outpatient medical claims. Is responsible for safeguarding the public relations and confidentiality of the organization and its records by consistent professional conduct.

Education:

• High School Diploma or successful completion of an equivalent High School Exam Required

Licensure:

• None

Experience:

• Three to six months of related work experience in medical billing preferred

The following is a summary of the major job duties of this job. Other duties may be performed, both major and minor, which are not mentioned below. Specific activities may change from time to time.

1. Reviews all claims for complete and accurate information.
2. Contacts other SOMC departments, physician offices, and insurance companies to obtain necessary information to file complete, accurate, and timely claims.
3. Processes, edits, and submits all claims for the organization.
4. Follows up on Commercial, Worker's Comp, VA, and Governmental claims by phone calls to the insurance companies, websites, or any online resources available.
5. Works with the patient/guarantor by phone to assist with any questions regarding unpaid claims. Obtains information from the patient/guarantor with which to submit the claim for payment (i.e., claim forms, Medicare Secondary Payer (MSP) Questionnaire, etc.)
6. Processes administrative appeals, reinstatements, and rejections of insurance claims.
7. Completes account follow up daily, maintaining established goals, and notifies the Lead Specialist, when necessary, of issues preventing achievement of such goals.
8. Analyzes daily correspondence (denials, underpayments) to appropriately resolve issues.
9. Adheres to HIPPA regulations by verifying pertinent information to determine caller authorization level receiving information on account.
10. Identifies billing and coding issues with individual claims, notifying medical billers for correction.
11. Makes determinations through on-line systems of patient eligibility, coverage, and reviews status of claims.
12. Performs other duties as assigned.

Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions of the position in accordance with applicable law. A full job description is available upon request.

Southern Ohio Medical Center is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to age, ancestry, color, disability, ethnicity, gender identity, or expression, genetic information, military status, national origin, race, religion, sex, gender, sexual orientation, pregnancy, protected veteran status or any other basis under the law.