Claims Specialist

Claims Investigator

This position is responsible for investigating claim denials; performing claim rebills; scanning & mailing documents; handling large volumes of documents; researching using hospital and insurance portals; opening, sorting, and importing incoming correspondence; contacting health insurance companies in order to obtain the status of previously submitted appeals.

Duties and Responsibilities:

• Investigates Claims Denials.
• Handles large volumes of documents, including accurately scanning and mailing documents.
• Utilizes increased knowledge of the industry, hospital revenue cycle, and payers/insurance companies to document the account and provide information and details to support paralegal's/attorney's pursuit for additional reimbursement.
• Works within the client's Patient Accounting system, payer portals and/or websites, and will utilize proprietary software to research accounts in the work queue.
• Is comfortable, skilled, assertive, cordial, and professional on the telephone to follow up on submitted appeals.
• Opens, sorts, and imports incoming correspondence into the office database.
• Navigates through various computer systems and applications to find information about insurance claims.
• Greets and assists onsite guests.
• Answers calls for Claim status and Appeal status.
• Performs any other administrative duties as may be necessary.
• Performs other related duties as assigned by management.

Qualifications:

• Bachelor's Degree (BA) from four-year college or university, or one to two years of related experience and/or training, or equivalent combination of education and experience.
• Other skills required:
  1. Previous experience in office administration or another related field.
  2. Basic working knowledge of the US healthcare system.
  3. Ability to prioritize and multitask.
  4. Excellent written and verbal communication skills.
  5. Proficiency in Microsoft Office, including Word and Excel.
  6. Highly attentive to detail.
  7. Excellent organizational and time management skills.
  8. Clear, concise, and logical writing style.
  9. Computer-savvy, able to learn new applications/software quickly.

Competencies:

• Adaptability - Adapts to changes in the work environment; Manages competing demands; Changes approach or method to best fit the situation; Able to deal with frequent change, delays, or unexpected events.
• Analytical - Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data; Designs work flows and procedures.
• Business Acumen - Understands business implications of decisions; Displays orientation to profitability; Demonstrates knowledge of market and competition; Aligns work with strategic goals.
• Business Necessity The needs of the employer may be dependent on responding to and anticipating rapidly changing external and internal demands in all aspects of how business is conducted. This may include, but is not limited to, organization structure, finances, goals, personnel, work processes, technology, and customer demands. Therefore, it may become necessary to make modifications to how business is conducted, and work is accomplished, with minimal or no advance notice to employees. Accordingly the employee must be capable of adapting, with minimal or no advance notice, to changes in how business is conducted, and work is accomplished, with no diminishment in work performance.
• Customer Service - Manages difficult or emotional customer situations; Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance; Meets commitments.
• Delegation - Delegates work assignments; Matches the responsibility to the person; Gives authority to work independently; Sets expectations and monitors delegated activities; Provides recognition for results.
• Dependability - Follows instructions, responds to management direction; Takes responsibility for own actions; Keeps commitments; Commits to long hours of work when necessary to reach goals; Completes tasks on time or notifies appropriate person with an alternate plan.
• Diversity - Demonstrates knowledge of EEO policy; Shows respect and sensitivity for cultural differences; Educates others on the value of diversity; Promotes a harassment-free environment; Builds a diverse workforce.
• Ethics - Treats people with respect; Keeps commitments; Inspires the trust of others; Works with integrity and ethically; Upholds organizational values.
• Interpersonal Skills - Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others' ideas and tries new things.
• Judgement - Displays willingness to make decisions; Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate people in decision-making process; Makes timely decisions.
• Quality - Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors own work to ensure quality.
• Quality Management - Looks for ways to improve and promote quality; Demonstrates accuracy and thoroughness.
• Quantity - Meets productivity standards; Completes work in timely manner; Strives to increase productivity; Works quickly.
• Written Communication - Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Presents numerical data effectively; Able to read and interpret written information.