Insurance Clerk

POSITION OVERVIEW (non-exempt):

The insurance clerk is responsible for the claims process of the health center's revenue process which includes accurate and timely claim creation, follow-up and appeal of denials/rejections received from third-party payers. The insurance clerk will manage their assigned work to ensure payer appeal/filing deadlines are met and achieve optimal payment for services rendered. This role will embed in the revenue cycle in the role required to head off issues, edits, financial clearance and any additional needs as they arise.

QUALIFICATIONS:

• High School Diploma required;
  Associates degree in a business-related field preferred.
• Experience and knowledge of accounts receivable, medical terminology, EOBS, CPT/HCPCS & ICD-10 codes, CMS 1500, UB04, authorizations/referrals and insurance regulations preferred.
• Experience with automated systems and strong knowledge in PC Programs, MS Office and web-based programs, and research required.
• Rural Health Clinic billing and Critical Access knowledge preferred.

ACCOUNTABILITY:

Revenue Cycle Supervisor and Revenue Cycle Director

DIRECT REPORTS:

None

POSITION-SPECIFIC REQUIREMENTS:

Claims Processing & Billing Operations

• Prepare, review, and submit clean insurance claims to third-party payers electronically or via paper formats (UB'04, CMS'1500), ensuring completeness and accuracy.
• Identify correct payer responsibility, including primary, secondary, and tertiary insurance, and bill appropriately.
• Utilize automation and electronic tools to verify eligibility, check claim status, and obtain accurate billing information.
• Monitor assigned work queues and reports in accordance with departmental priorities.
• Maintain required productivity standards, averaging 80-100 claims per day, including clean claim reviews.
• Utilize electronic health record (EHR) systems and paper records to perform billing duties while maintaining an accurate, legally compliant medical record.

Accounts Receivable, Follow'Up & Denials Management

• Follow up with insurance companies to resolve unpaid, denied, or rejected claims in a timely manner.
• Review, research, and process denied or rejected claims using multiple systems and web'based platforms.
• Organize denial and rejection workflows to identify patterns by payer, CPT, diagnosis, and other contributing factors.
• Identify and monitor negative denial or rejection trends; communicate findings to leadership and impacted departments to mitigate reimbursement risk, unsuccessful appeals, and increased write'offs.
• Participate in AIR cleanup initiatives and special projects as assigned by management.

Patient & Payer Communications

• Respond to patient inquiries regarding balances, copays, deductibles, write'offs, and non'covered services in a professional and empathetic manner.
• Manage assigned accounts and communicate with providers, patients, insurance representatives, and other stakeholders to resolve billing issues and facilitate timely payment.
• Consult with directors, supervisors, team members, and appropriate resources to resolve complex billing and collection issues.

Compliance, Quality & Regulatory Adherence

• Adhere to billing requirements for Medicare, Medicaid, managed care, commercial insurance, workers' compensation, and other government programs.
• Ensure compliance with all federal and state regulations governing billing and reimbursement.
• Maintain strict confidentiality of patient and financial information in accordance with HIPAA guidelines.
• Follow departmental standards, policies, and procedures; escalate compliance concerns to leadership as appropriate.

Interdepartmental Collaboration & Organizational Support

• Collaborate with internal departments to address A/R and payer'related issues that may impact cash flow, filing timeliness, appeals outcomes, denials, or write'offs.
• Communicate proactively with departments regarding trends or issues affecting reimbursement.
• Participate in departmental and team meetings focusing on AIR processes, performance metrics, and trends.

Customer Service, Teamwork & Professional Development

• Provide professional, courteous, and responsive customer service to internal and external customers.
• Function as a contributing team member while meeting productivity goals, deadlines, and quality standards.
• Educate and train other staff members as directed by the director.
• Attend all required meetings, in'services, and training sessions.
• Be flexible with work hours as needed to meet departmental coverage requirements.

Administrative & General Duties

• Perform administrative tasks including answering phones, faxing, filing confidential documents, and routine email and internet use.
• Perform other related duties as assigned or required by management.

WORK ENVIRONMENT
:

• Works in a well-illuminated, climate-controlled environment
• May come in contact with hazardous chemical or treatment modalities
• Possibility exists of exposure to communicable diseases
• Involvement in inpatient care may result in unavoidable work-related illness or injury
• Work environment is comfortable,…