Insurance Claim Specialist

REPORTING RELATIONSHIPS

Reports to: Assist Manager of Claims Management

GENERAL SUMMARY

Works under the supervision of the Assistant Manager of Claims Management and Lead Insurance Claim Specialists. The Insurance Claim Specialist's primary job functions is to analyze, process, submit, and follow up on inpatient and outpatient medical claims. Is responsible for safeguarding the public relations and confidentiality of the organization and its records by consistent professional conduct.

QUALIFICATIONS

Education:

• High School Diploma or successful completion of an equivalent High School Exam Required

Licensure:

• None

Experience:

• Three to six months of related work experience in medical billing preferred

Interpersonal Skills:

• Basic level of analytical ability necessary in order to gather and interpret data related to the billing process.

• Knowledge of medical terminology is helpful but not required if willing to acquire this knowledge.

Essential Technical/Motor Skills:

• Inputting Data, typing, copying, calibrating equipment, speaking clearly, answering telephones, precise eye, hand & foot coordination, fingering, fine dexterity, handling & gripping.

Essential Physical Requirements:

• The physical demand level is light to medium.

• Occasionally lifts/carries 35 pounds or less.

• Stands and/or walks one to four hours, with rest, when filing and photocopying.

• Sits for five to eight hours continuously when entering data into the hospital Information Systems.

• Must have the ability to use hands for repetitive simple grasping and fine manipulation when answering the telephone and using office equipment.

• Pushing and pulling is required when filing.

• Bending, squatting, climbing is occasionally required; reaching above shoulder level is continuously required.

Essential Mental Requirements:

• Calculations, manipulating numbers, interpreting numbers, analyzing, attention to detail, memory, problem solving, and reasoning.

• Has occasional contact with the general public and the customer.

• Occasionally works under close supervision and most of the time without the assistance of other personnel.

• Must be able to cope with occasional deadlines and irregular schedules; continuously requires the ability to concentrate when using the Hospital's Information Systems.

Essential Sensory Requirements:

• Good vision and the ability to hear are continuously required reviewing patient's financial folder and inputting information into the Hospital's Information Systems.

• The ability to speak is required occasionally. Ability to feel & to distinguish color.

Exposure to Hazards:

• Normal office environment with little exposure to excessive noise, dust, temperature and the like.

Other:

• Must be familiar with and have the ability to use all relevant office equipment, including Hospital's Information Systems and Person

JOB SPECIFIC DUTIES AND PERFORMANCE EXPECTATIONS

The following is a summary of the major job duties of this job. Other duties may be performed, both major and minor, which are not mentioned below. Specific activities may change from time to time.

• Reviews all claims for complete and accurate information.

• Contacts other SOMC departments, physician offices, and insurance companies to obtain necessary information to file complete, accurate, and timely claims.

• Processes, edits, and submits all claims for the organization.

• Follows up on Commercial, Worker's Comp, VA, and Governmental claims by phone calls to the insurance companies, websites, or any online resources available.

• Works with the patient/guarantor by phone to assist with any questions regarding unpaid claims. Obtains information from the patient/guarantor with which to submit the claim for payment (i.e., claim forms, Medicare Secondary Payer (MSP) Questionnaire, etc.)

• Processes administrative appeals, reinstatements, and rejections of insurance claims.

• Completes account follow up daily, maintaining established goals, and notifies the Lead Specialist, when necessary, of issues preventing achievement of such goals.

• Analyzes daily correspondence (denials, underpayments) to appropriately resolve issues.

• Adheres to HIPPA regulations by verifying pertinent information to determine caller authorization level receiving information on account.

• Identifies billing and coding issues with individual claims, notifying medical billers for correction.

• Makes determinations through on-line systems of patient eligibility, coverage, and reviews status of claims.

• Performs other duties as assigned.

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Southern Ohio Medical Center is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to age, ancestry, color, disability, ethnicity, gender identity, or expression, genetic information, military status, national origin, race, religion, sex, gender, sexual orientation, pregnancy, protected veteran status or any other basis under the law.