Insurance Specialist

Summary

Reviews Explanation of Benefits (EOB’s), incoming reimbursements via electronic deposits or paper checks, and remittance advice received from payors to ensure accurate distribution and posting of payments to accounts.

Audits to ensure that all required billing documents are available and correct. Performs account maintenance and follow-up on all denials and outstanding claims.

Qualification Requirements

Must be proficient in processing medical insurance claims. Knowledge of medical billing / collection practices and above average understanding of debits and credits are required.

Basic medical coding and third-party operating procedures and practices is required.

Minimum Qualifications

• High School Diploma or equivalent
• 2 years of medical insurance claims experience
• Ability to read and interpret the most current CPT and ICD coding is preferred.
• Proficiency in Microsoft Office (Word, Outlook, Excel). Above average understanding and proficiency using word processing and spreadsheets.
• Computer skills also include knowledge of applicable EHR, Practice Management, Allscripts PM, Clinical Module Medical Records and Document Manager systems.
• Familiarity with CMS 1500 claim form completion.
• Passage of a criminal background check, OIG exclusion, and drug screenings.
• Valid driver’s license and reliable transportation.

Knowledge, Skills and Abilities

• Detail oriented and excellent records maintenance skills.
• Ability to communicate effectively both orally and written.
• Proactive individual with the ability to be a self-starter with strong independent decision-making skills and attention to detail.
• Ability to foster a cooperative work environment. Possess willingness to accept direction and guidance and to perform repetitive tasks.
• Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
• Knowledge of healthcare billing procedures, documentation, and standards.
• Knowledge of appropriate billing and payment cycles for third party payor accounts.
• Ability to make evaluative judgments.
• Skill in the use of personal computers and related software applications to include word processing, outlook, and excel.
• Ability to function well while involved in multiple task assignments. Ability to concentrate on details and deal with constant interruption.

Skill in organizing resources and establishing priorities.

• Knowledge of operational characteristics and procedural requirements of third-party payors.
• Knowledge of procedural requirements and ethical standards for follow-up of overdue accounts.
• Ability to analyze medical records and identify billable services.
• Knowledge of credit and collection principles, process regulations, and standards.

Supervisory Responsibilities

None

Essential Functions

Process assigned third party payor EOBs by referencing date of service, amount billed, and amount paid, any assigned contractual write-offs or patient responsibilities.

Annotates each account with information from EOB.

Ability to reconcile patient accounts and recognize potential errors that require corrections, to include overpayments.

Confer with Billing and Reimbursement Supervisor regarding delinquent accounts and determine appropriate action which may include special adjustments and / or write-offs.

• Send in adjustments for offsets for overpayments within third party payor guidelines.
• Post recoupment when it shows up on remit.
• Research incoming payments and remittance advice and ensure accurate distribution of all payments.
• Responsible for Follow Up Work Queues for assigned third party payor to ensure that no claims are missed for reimbursement a minimum of every 45 days.
• Handle all matters related to assigned third party payor rejections.
• Communicate directly with patients / guarantors and / or insurance companies to verify correct benefits.
• Maintain document master files for back up and verification of data entered such as charge batch entry & receipt batch entry reports, billing reports, reports from clearing house, file submission reports etc.
• Regularly review all paper and electronic bulletins and correspondence from assigned third party payor for up-to-date changes and keep for easy reference.
• Stay apprised of assigned third party payor requirements and guidelines to ensure we are complying and maximizing reimbursements.
• Keep all assigned third party payor reference materials, monthly bulletins, manuals, and forms organized.
• Follow all safety policies and procedures. Recommend changes or updates as needed to safety policies and procedures.
• Participate in required safety training and drills.
• Attend continuing education programs related to coding and reimbursement.
• Adhere to all billing requirements of assigned third party payor.
• Maintain confidentiality and adhere to all HIPAA guidelines and regulations.
• Perform related work as required to accomplish the mission of the organization.
• Post dialysis charges if applicable.
• Serve as a back-up for posting other third-party payor payments as needed.

Physical Demands

• The employee must frequently lift and / or move up to 10 pounds. The employee is expected to use the appropriate tools provided such as hand carts to carry heavier loads.
• This position requires eyesight (corrected or uncorrected) that allows the employee to accurately read job related materials, accurately read and record patient related information, and any other functions that require the employee to accurately see data.
• Keying of data requires repetitive motion.
• While performing the duties of this job, the employee is regularly required to stand and talk or hear.
• The employee is occasionally required to sit and stoop, kneel, or crouch and requires full range of body motion, manual and dexterity and eye-hand coordination.
• The employee is required to spend a significant amount of time on the phone and therefore are expected to use the hands-free headsets provided to help avoid injuries.

Work Environment

Work Schedule is Monday- Friday, 8 am to 5 pm. Slight modifications may be made to this schedule with approval from the manager.

Work is normally performed in a typical interior / office work environment. The noise level is usually moderate. Low risk of exposure to blood borne pathogens and OPIM.

Must be able to work overtime hours as needed to accomplish the mission of the organization.

The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this job.

They are not intended to be an exhaustive list of all responsibilities, duties and skills required of the position. All employees may have other duties assigned at any time.

Benefits : 401(k) includes Safe Harbor and Profit Sharing / Choice of Medical Insurance Plans / Dental / Paid Disability and Life Insurance / Optional Life, Accident and Critical Insurance / Generous Paid-Time-Off

Eastern Nephrology is the region’s largest, private medical practice specializing in diseases and disorders of the kidney.

Our continued growth is a direct result of providing excellent service and care to our patients. ENA is always seeking talented and compassionate clinical and administrative people to join our practice family.

Eastern Nephrology is an equal opportunity employer. Applicants will not be discriminated against because of race, color, creed, sex, sexual orientation, gender identity or expression, age, religion, national origin, citizenship status, disability, ancestry, marital status, veteran status, medical condition, or any protected category prohibited by local, state or federal laws.

We are an E-Verify Employer. Pre-employment background checks are required for all employment positions. If you are a qualified individual with a disability and are unable or limited in your ability to use or access the online application system process due to your disability, please contact the Human Resources Department at 252-864-2049 to request assistance.

The company provides reasonable accommodations to qualified individuals with a disability to enable them to effectively participate in the application process, as required by law.