JOB SUMMARY: The Insurance Follow Up and Denials Specialist is responsible for managing and resolving assigned aging insurance accounts to ensure timely and accurate reimbursement. This role actively follows up on unpaid, underpaid, and incorrectly processed claims by working assigned work queues. This role communicates directly with insurance payers to investigate claim status, resolve denials, and address payment discrepancies while ensuring compliance with timely filing and payer-specific requirements.

Blood Borne Pathogen Exposure: No 

Duties and Responsibilities:

1. Review and work assigned aging insurance accounts to ensure timely resolution and payment (Aging AR & IBAR).
2. Contact insurance companies via phone, payer portals, and electronic systems to obtain claim status and resolve issues.
3. Investigate and resolve unpaid, underpaid, or incorrectly processed claims.
4. Ensure adherence to timely filing payment requirements.
5. Research and resolve technical and administrative denials (coverage issues, coding edits, missing information) by actively working assigned Denial queues.
6. Submit corrected claims, reconsiderations, and appeals when applicable.
7. Identify clinical or complex denials and route to the Manager with supporting documentation.
8. Evaluate remittance advice to identify payer underpayments and escalate for contract review, when necessary, by actively working the Pay Variance queues.
9. Upload or request medical records, coding queries, or additional documentation required by payers.
10. Communicate directly with insurance representatives to resolve claim disputes, request adjustments and clarify payer rules.
11. Monitor payer portal messages, correspondence, and attachments for updates impacting payment.
12. Escalate systemic payer issues to the Manager, Revenue Cycle.

Qualifications:

1. High school diploma or equivalent required, associate degree in healthcare administration, business, or related field preferred.
2. Minimum 2-4 years of experience in healthcare insurance follow-up, accounts receivable, or revenue cycle operations.
3. Strong knowledge of insurance billing and reimbursement processes for commercial, Medicare, Medicaid, and managed care payers.
4. Experience researching and resolving technical and administrative denials, including coverage issues, coding edits, and missing or invalid information.
5. Ability to submit corrected claims, reconsiderations, and appeals with appropriate supporting documentation.
6. Proficiency in using payer portals, electronic claim systems, and electronic health record (EHR) or billing systems, knowledge of Cerner/Oracle Health Patient Accounting a plus.
7. Strong written and verbal communication skills for effective interaction with insurance representatives and internal stakeholders.
8. Strong analytical, organizational, and problem-solving skills with attention to detail.

Physical Demands:

1. Prolonged periods of computer use.
2. Ability to lift and move boxes/files up to 35 lbs., if required.