JOB SUMMARY: The Insurance Specialist plays a key role in the revenue cycle by ensuring accurate and timely posting of insurance payments to patient accounts. This position is responsible for researching and resolving denied, unpaid, or partially paid claims, and serves as a subject matter expert for specific insurance plans and payers. The Insurance Specialist collaborates with clinical staff, the Business Services Manager, and billing teams to address reimbursement issues, support accurate claim submission, and ensure compliance with regulatory standards and HIPAA guidelines. This role also maintains up-to-date knowledge of insurance policies and delivers knowledgeable, professional service to patients, guarantors, and clinical staff regarding insurance benefits and account status.

1. Post insurance payments to patient accounts accurately and in accordance with established procedures.
2. Research and follow up on denied, unpaid, or partially paid claims for all insurances, reviewing the underlying reason to determine the appropriate action.
3. Contact insurance companies to follow up on claims, resolve denials, pre-certify services, and address other issues as they arise, documenting all activity on the patient account per established policies.
4. Contact patients and/or clinical staff as needed to obtain current and accurate insurance information, ensuring it is correctly entered into the billing system per established policies.
5. Request corrected or updated insurance information from patients to ensure charges are billed to the correct insurance company, including follow-up on refunds and generation of corrected claim forms.
6. Respond to incoming calls from patients, guarantors, clinical staff, and payors to answer account-related questions while maintaining HIPAA compliance.
7. Bring reimbursement concerns to the attention of the Business Services Manager, including changes in reimbursement for specific codes, out-of-network denials, and bundling/unbundling of CPT codes.
8. Discuss with the Business Services Manager any charges requiring write-off due to timely filing or other issues.
9. Notify the Patient Services Department when payments are received for bad debt balances.
10. Maintain up-to-date knowledge of health insurance policies, regulations, and payer guidelines, and contribute to ongoing peer training and team development.
11. Ensure compliance with all regulatory standards, HIPAA guidelines, and administrative and departmental policies.

EDUCATION, CERTIFICATION, LICENSURE, REGISTRATION:  High School Diploma or GED required.

EXPERIENCE, KNOWLEDGE, SKILLS and ABILITIES: 

1. Minimum of two years of medical office billing experience
2. Knowledge of clinic policies and procedures
3. Knowledge of medical terminology and insurance practices
4. Knowledge of computer programs and applications
5. Knowledge of grammar, spelling, and punctuation to type correspondence
6. Skilled in gathering, interpreting, and reporting insurance information
7. Skilled in trouble-shooting insurance problems and claims
8. Ability to identify claim problems and recommend solutions
9. Ability to sort and file insurance forms and associated information

REASONING ABILITY:

1. Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. 
2. Ability to interpret a variety of instructions furnished in written, oral, or schedule form.

INTERPERSONAL SKILLS:

1. Must interact and communicate both verbally and in written form.
2. Must interact and exchange information regarding patients with physicians and other departmental personnel, and outside agencies on a frequent basis while respecting the confidentiality of patient information.

PHYSICAL DEMANDS:

1. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  
2. While performing the duties of this job, the employee is regularly required to talk or hear.  
3. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
4. Specific vision abilities required by this job include close vision and the ability to adjust focus.

WORK ENVIRONMENT:

The work environment described here are representative of those an employee encounters while performing the essential functions of this job.  This position involves potential exposure to infectious diseases.  Colleagues are offered appropriate vaccinations and safety training.

COMMENTS:

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of the job.  It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified.  Other functions may be assigned and management retains the right to add or change the duties at any time.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job.