Insurance Follow-up Specialist

GENERAL SUMMARY:

The Insurance Follow-up Specialist is responsible for timely, efficient and accurate follow-up on outstanding insurance and credit balances. In addition to insurance follow-up, this role is responsible for completing any reworks, re-submissions, reconsiderations, appeals or claim communications timely and according to the requirements of the payer. The Insurance Follow-up Specialist answers questions from payers, departmental staff, other outside agencies, patients or family verbally, through the mail or via phone as needed.

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values.

2. *Performs follow-up on all outstanding claims and takes the appropriate action to ensure timely and accurate reimbursement following the payers filing guidelines

3. Reviews and analyzes all claims for correct and complete patient and insurance information, service dates, and charges.

4. *Makes outbound calls to payers and accesses payer websites.

5. *Maintains knowledge of current billing guidelines and third party payer regulations.

6. *Investigates reason for errors by communicating with specified department personnel and makes the necessary corrections within system.

7. Actively researches State and Federal regulations and billing guidelines to stay current to ensure compliance.

8. *Contacts patients or employers as necessary for correct health plan information by calling or sending correspondence as needed.

9. *Responds to all inquiries, billing rejections, and other correspondence and phone requests in an efficient and effective manner.

10. *Completes reconsiderations and appeals as needed.

11. Works with the appropriated department concerning any coding issues or reviews.

12. Follows Medical Center protocols in communicating and releasing patient information.

13. Documents all activities on accounts in the hospital patient accounting system.

14. Identifies issues or trends with accounts and makes suggestions for possible resolutions.

15. Works closely with the Hospital Billing Specialists to resubmit claims and resolve errors as needed.

16. Performs other related projects and duties as assigned.

(Essential Job functions are marked with an asterisk "*". Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly different roles or work-specific differences as needed.

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:

1. Knowledge of patient accounting operations and standard techniques.

2. Knowledge of credit and collection practices, third party payer regulations and Joint Commission regulations.

3. Knowledge of federal, state and facility regulations including COBRA, HIPPA, Medicare, Medicaid and Corporate Compliance Plan.

4. Knowledge of billing and third party reimbursement websites for resource support and claim status updates.

5. Knowledge of computer hardware equipment and software applications relevant to work functions.

6. Knowledge of CPT and ICD-10 codes.

7. Ability to minimum productivity standards set forth by the department.

8. Ability to communicate effectively both verbally and in writing.

9. Ability to prioritize work demands and work with minimal supervision.

10. Ability to establish and maintain effective working relationships with all levels of personnel, medical staff, volunteer and ancillary departments.

11. Ability to maintain confidentiality relevant to sensitive information.

12. Knowledge of the Centers for Medicare and Medicaid Services (CMS), to include CCI, MUE, and OCE editing practices as they relate to government claims.

13. Strong analytical, problem solving, and communication skills.

14. Advance work knowledge by participating in continuing education in-services, webinars, teleconferences, reading periodicals/literature and seeking ongoing development opportunities.

15. Ability to react and effectively perform work under stressful situations.

16. Ability to maintain regular and punctual attendance.

EDUCATION AND EXPERIENCE:

High school diploma or equivalency required. Associates degree in business or accounting related field preferred. One (1) year of experience in a healthcare setting, preferably working in billing, insurance follow-up or accounting required. Training or prior experience in CPT/ICD-10 coding desired. Must be at least 19 years of age to witness legal consents.

PHYSICAL REQUIREMENTS:

(Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.)

(DOT)-Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.