Position Summary: 

Fulfills all requirements of   Insurance Specialist I, as well as serving as a group leader by participating in staffing and employment issues.  Serves as a resource specialist within the department.  Trains Insurance Billing Specialists I and related support staff. Works closely with Director, Manager, Supervisor and Application Analyst on day to day priorities and to maintain a high level of integrity within the unit. Takes the necessary action to complete all types of complex insurance billings and appeals.  Reviews and analyzes the insurance processing procedures to identify potential problem areas and makes suggestions for more streamlined processing.  Prepares reports as required and requested.  Works with insurance payers on problem claims and processes. Resolves outstanding Accounts Receivable and credit balances as assigned.

Education: 

High school diploma or equivalency required. 

CPC, CCA, RHIA, RHIT certification in medical billing and coding or Associates degree preferred.

Experience: 

Minimum 3 years experience in insurance billing or CPC certified.  Must demonstrate current competencies applicable to the job and have proven experience in performing required tasks independently while contributing to the team environment.  Must maintain a knowledge of medical terminology, CPT and IC

D‐10 Coding and insurance regulations.  Strong organizational and customer service skills are a must.  Previous experience in performing in a high volume and fast paced environment and demonstration of self‐motivation to develop and maintain the knowledge and skills for the position.

Essential Functions: 

1. Identifies and evaluates denials for assigned payers and/or specialties to determine specific issues and patterns that need to be addressed.  Serves on Denial Task Force(s) and assists in developing action plans to reduce denials and streamline clean claim submissions.

2. Exports data, prepares spreadsheets, creates and runs reports as needed to be used in the resolution of outstanding claims (ex.  trending, projects, worklists) Identifies trends and provides appropriate follow‐up for claims that require correction/appeal.

3. Demonstrates skills and proficiency in analyzing complex billing problems, prepares appeals, challenges payer policies and pursues appeal turnover when necessary.

4. Works with team and department management to develop and train internal rejection protocols.  Keeps current with coding knowledge, reimbursement policies, payer guidelines and other sources in order to ensure best practice procedures are followed.

5. Ensures staff adherence of protocols by audit and education.

6. Identifies and promptly reports payer, system or billing issues.  Works with Applications Analyst, Supervisor, Manager and/or Director to provide recommendations and resolution.

7. Works with team and payers to ensure timely resolution of credit balances as assigned.  Aids in the preparation of annual escheatment documentation.

8. Leads any payer specific external claim audit activity, worked in combination with Management, Compliance, Medical Records and Clinical Operations.

9. Serves as a group leader by performing one or more of the following duties:  employee training, routing work assignment, participation in employment issues.

10. Reviews requested adjustments from Specialists, approving low dollar adjustments within policy guidelines.  Gathers all information or documentation needed for Director approval of high dollar adjustments.

11. Performs testing and monitoring of new system logic or process with Business Analyst and/or Manager.

Other Duties: 

1. Answers phone calls and correspondence providing requested information to aid in the resolution of account balances.

2. Maintains knowledge and performs within the compliance of Guthrie Medical Group and payer guidelines.

3. Provides feedback related to workflow processes in order to promote efficiency.

4. Utilizes Epic system functions accurately to perform assigned tasks.  Example:  Charge corrections, invoice inquiry, credits, charge review, claim edit, 277 rejections, etc.   Trains staff on same as needed.

5. Demonstrates excellent customer service skills for both internal and external customers while promoting the same in the team environment.

6. Maintains strict confidentiality related to patient health information in accordance with HIPAA compliance.

7. Assists with and completes projects and other duties as assigned.

updated 3-15-24