Sr. Insurance Follow-up & Denial Specialist

Schedule:

FT, Mon - Fri 8:00 - 5:00 (hybrid - in office 2 days a week)

The Sr. Insurance Follow-up & Denial Specialist is responsible for corresponding with commercial and government health insurance payers to address and resolve outstanding insurance balances and denials in accordance with established standards, guidelines and requirements. The role identifies and analyzes underpayments to determine the reasons for discrepancies, the root cause, and processes appeals and reconsiderations. The specialist conducts follow-up activities through phone calls, online processing, fax, and written correspondence, leveraging work queues to organize work efficiently.

Work also includes reviewing insurance remittance advices, researching denial reasons and resolving issues through well‑written appeals.

• Follows up on insurance and government payor claims to research and resolve unpaid claims and denials in follow‑up work queues by contacting payers and/or patients for status. Identifies trends and assists lead/supervisor to provide the team with insurance plan updates, reconsideration/appeal recommendations, and opportunities for improvement to aid in quality and productivity requirements for their roles.
• Responsible for obtaining reimbursement information when payment and remit are both provided via paper. Communicates effectively over the phone and through written correspondence to explain why a balance is outstanding and denied using accurate and supported reasoning based on EOBs, medical records, and payer specific requirements.
• Resubmits claims with necessary information and medical records when requested by payer through paper or electronic methods to ensure payments from third‑party payors.
• Monitors and reviews denial reason codes, plan limitations and works with other areas of revenue cycle when necessary to resolve issues.
• Organizes open accounts by denial type or payer to quickly address them in bulk with representatives over the phone, via spreadsheet, utilizing an online payer portal, etc.
• Applies a thorough understanding/interpretation of Explanation of Benefits (EOBs) and remittance advices. Accurately documents patient accounts of all actions taken in the system.
• Responsible for resolving work queues according to the prescribed priority and/or per the direction of management and in accordance with department expectations.
• Assists in managing and resolving accounts from the workloads of other team members to prevent backlogs.
• Identifies high‑risk accounts and prioritizes follow‑up actions accordingly.
• Assists with training of staff by contributing to the development of ongoing training and reference material to aid in the consistency of handling appeals and reconsideration of claims.
• Assists with identifying future development opportunities for team members.
• Recognizes when additional assistance is needed to resolve insurance balances and escalates appropriately and timely through defined communication and escalation channels.
• Anticipates & identifies potential areas of concern or improvement within the follow‑up functions. Proactively assists with or takes initiative on escalated issues as necessary or as directed by leadership.
• Keeps current on payor requirements through workshops, newsletters, and websites.
• Complies with Federal and State billing requirements. Also complies with HIPAA and Electronic Data Interface (EDI) transaction formats.
• Other duties as assigned by leader and organization.

• High School Diploma or GED equivalent – Required
• Associate's Degree from an accredited college or university in Information Systems, Business, Finance, or related field – Preferred

• Minimum 3 years of experience working with commercial and government billing and reimbursement processes – Required

• Organized, self‑motivated, and able to work independently of direct supervision to carry out responsibilities.
• Intermediate computer skills including the use of spreadsheet programs and word processing programs.
• Knowledge of general concepts and practices that relate to hospital and professional billing, collection and…