Insurance and Claims Specialist

Position Purpose

The Insurance and Claims Specialist will review and correct claim errors ensuring accurate, timely claim submission and account follow-up to assigned payors and reimbursement on first claim submitted. The Specialist will appeal healthcare claims denied by third-party payors to obtain reimbursement and handle difficult, hard to collect accounts that have been deemed by the insurance company as unpayable. The Specialist will conduct analysis and resolve incorrect reimbursement issues and credit balance resolution with payors.

This position is responsible to know all state/federal regulations that relate to contracts and to the appeal process and/or government payor billing and follow-up regulations to include CCI, LCD/NCD and medical necessity rules.

The Insurance and Claims Specialist will review and correct claim errors ensuring accurate, timely claim submission and account follow-up to assigned payors and reimbursement on first claim submitted. The Specialist will appeal healthcare claims denied by third-party payors to obtain reimbursement and handle difficult, hard to collect accounts that have been deemed by the insurance company as unpayable. The Specialist will conduct analysis and resolve incorrect reimbursement issues and credit balance resolution with payors.

This position is responsible to know all state/federal regulations that relate to contracts and to the appeal process and/or government payor billing and follow-up regulations to include CCI, LCD/NCD and medical necessity rules.

• Work assigned Work Queues to correct errors, ensuring accurate claims and reimbursement on first claim submission.
• Audit denials and payment variances to determine root cause and correction as required.
• Auditing payment variances ensuring appropriate reimbursement.
• Provide specific and in depth contract knowledge to ensure maximum reimbursement of healthcare claims.
• Resolve credit balances by reviewing payments, adjustments or transfers correcting the patient account to reflect an accurate account receivable balance.
• Work with leadership and other internal departments to improve processes, increase accuracy, create efficiencies and decrease denials to achieve the overall goals of Renown Health.
• Maintain a current knowledge of CPT/HCPCS, ICD, DRG, HCFA forms, ability to manipulate and analyze 837 and all other HIPAA transaction sets.

This position is required to operate within policy and procedural guidelines that will ensure accurate accounts receivable reporting and is compliant with policy and procedural guidelines consistent with Renown Health goals and objectives.

This position does not provide patient care.

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Requirements - Required and/or Preferred

Education:

Must have working-level knowledge of the English language, including reading, writing and speaking English. Associates degree preferred.

One year healthcare billing office experience with extensive knowledge of healthcare billing, government and third party payor requirements. Associate degree or certification in accredited billing certification may be accepted in lieu of years of experience.

None.

None.

Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel and Word and have the ability to use the computer to complete online learning requirements for job‑specific competencies, access online forms and policies, complete online benefits enrollment, etc.