Insurance Reimbursement Specialist

BASIC FUNCTION:

Position reviews reimbursements from carriers, determines denial classifications and develops justifications for making billing changes to improve and increase revenue flow for the Seneca Nation Health System (SNHS). Routinely monitors accounts receivable to identify and resolve billing discrepancies.

GENERAL RESPONSIBILITIES:

Monitors changes in medical insurance industry and adjusts billing procedures accordingly based on individual carrier policies, communicates changes to billing and coding staff to improve quality and quantity of work processed for a clean claims submission.

Investigates reimbursement problems from improper coding and billing. Advise appropriate staff assisting with CPT, ICD 10, CDT and HCPC coding and documentation to decrease claim errors and increase third party payer revenue.

Provides excellent customer service while initiating inquiries, reconsiderations and appeals to resolve difficult claim issues and delinquent accounts by contacting insurance carriers via mail, email, phone or fax to obtain claim or policy information.

Reviews all outstanding balance reports through patient accounting system addressing unpaid claims and contacting the carriers with resubmissions, corrections or adjustments before the timely filing is exceeded.

Acts as a resource to promote cooperative staff efforts and provide and maintain high quality service to patient, physicians and other staff.

Identifies issues that may be related to the master ICD10, CPT, CDT, HCPC and insurance carrier list data files and advises appropriate staff that can review and make corrections for a resolution.

Assures confidentiality of information according to the Privacy Act of 1974, HIPAA and all SNHS policies.

Ensures compliance with applicable federal, state, and payer specific regulations.

Maintains and enhances professional growth and development by staying updated with the latest technologies and industry trends in the insurance field.

Knowledge of provider enrollment and insurance contracting.

General knowledge of patient registration, billing clerk and other business office positions to provide coverage and direction when needed.

Upholds and promotes the value and integrity of the Seneca Nation Health System (SNHS)’s mission statement. Will promote SNHS in a positive manner.

Provides care through a trauma-informed lens by incorporating key principles of both physical and psychological environment safety, trustworthiness and transparency, collaboration of decision-making during interactions, empowerment of patients by recognizing and building upon individual strengths, as well as recognizing and respecting the diversity of cultural backgrounds and sensitivity.

Participates and completes all mandatory staff meetings, trainings, and in-services.

Follows all policies and procedures of the department, SNHS, and Seneca Nation.

KNOWLEDGE, SKILLS, & ABILITIES:

Excellent interpersonal communication skills

Strong time management and organizational skills

Ability to provide and recommend solutions to problems

Ability to absorb critical information and instructions

Excellent analytical and problem - solving skills

Computer proficient in data entry and spreadsheet applications

Knowledge of medical terminology, coding policies and procedures

Able to collect, organize and interpret data from carriers with initiative to develop and implement changes in coding and billing while prioritizing workloads with multiple tasks

Must be able to adapt to a quickly changing electronic healthcare environment

QUALIFICATIONS:

High School graduate or equivalent is required.

Associate’s degree or AHIMA, AAPC, or AMBA certification with five years of experience in reimbursement, coding and clerical work in a hospital or medical setting is preferred.

Experience working in a mental health facility, hospital, medical center, outpatient health care setting, or Indian Health Service (IHS)/tribal health, preferred.