Insurance Specialist

The Insurance Specialist is responsible for day-to-day processing and follow-up of all insurance Authorizations and precerts, review of trial balances to identify and resolve problem area, formulation of action plans, prioritization of work, and analysis of results and customer service functions. Timely follow up to avoid untimely write offs and significant loss to the organization. Report errors and controllable denials to ensure training and corrections are put in place to reduce exposure to write offs, adjustments and loss of revenue.

Education
High School Diploma or GED

Experience
Two years of related experience. Requires working knowledge of specialized practices, equipment, and procedures.

Qualifications
*Ability to analyze and prioritize workloads
*Ability to be assertive without being abrasive
*Ability to work closely with others, and function as a team member
*Business like appearance
*Data entry experience in work environment. thirty-five (35) wpm
*Detail orientation
*Good verbal communication skills
*Knowledge and experience with Internet, Word, and Excel
*Proficiency in spelling, business letter writing, and medical terminology
*The ability to understand and work within multiple applications and systems. Both internally and externally
*Two years experience in insurance billing or insurance collections, and patient contact in a hospital, clinic, or physician office. May substitute customer service, teaching, sales, collection, or other occupations, which require control of conversation, heavy detail, and ability to negotiate and compromise when necessary

Area of Responsibilities
*Analyzes individual accounts within area of responsibility and develops an insurance follow-up and collection strategy which will result in payment of benefits in the shortest time possible. Follow-up requires processing daily selection report of unpaid accounts. Additional follow-up is maintained by use of individual account reminders and daily reminder worklist.
*G-Code management for Higgins Ip Op Obs
*Knowledge in multiple payer system and applications is required in required in order to do the appropriate follow up. This requires education in multiple site a policy provisions.
*Provides complete and comprehensive insurance billing and follow-up services, to all patients within area of responsibility, including those area of responsibility, including those with worker's compensation, auto insurance, other liability insurance, supplemental insurance, commercial insurance, vocational rehabilitation, Tricare, ChampVA, veterans Administration, and Blue Cross, within payer timely criteria and guidelines.
*Swing bed, IP, OP documentation audits for Higgins
*Analyzes work on hand, on a daily basis, and determines how to allocate manpower to achieve the greatest benefit to the area of responsibility. Determines when an extra effort, such as overtime or weekend work, is required, but is always mindful of the departmental budge and labor cost. Keeps team manager and department director informed as to substantial uses of overtime.
*Assures that commercial secondary and supplemental insurance is billed immediately upon receipt of primary payment. Primary payments and denials are reviewed prior to the secondary billing to insure readiness of secondary claim filing. In addition to improving A/R days and cash flow, success in this area will result in fewer patient complaints and inquiries.
*Back-up front office and clerical duties as requested, which will include scheduling, collections and registration of Higgins OP's
*Collecting Higgins quality data for Rehab and assisting Manager with projects as needed
*Develops and maintains high level of expertise in the requirements of individual payers, including all managed care plans, government plans client accounts
*Interviews prospects for placement on the team. Assesses likelihood that candidates will fit in and be able to contribute to the overall improvement of the team and the business office. The team's impression and recommendations, will be considered, by the team manager and department director in making a hiring decision.
*Maintains good relationships with doctor's offices for the purpose of exchange of mutually necessary information. Contacts doctor's office when outpatient facility claims are denied due to lack of authorization or question of medical necessity. Attempts to obtain clinical information and/or letter of medical necessity for appeal of denied charges. Maintains follow-up with insurance company for resolution by payment or adjustment. Success in this area will increase overturn of denials, lower a/r days and improved cash flow.
*Maintains good working relationships with other teams which includes transferring responsibility for accounts only when such transfers are justified. Reviews accounts to assure primary insurance claims are processed and resolved and appropriate documentation is received from the primary insurance in order to file to the next payer. Success in this area will result in maximum harmony and cooperation between teams
*Monitors work flow for the purpose of identifying and recommending solutions to problems, which cause delays in claims reaching readiness for billing. Develop and/or recommend edits to prevent ongoing errors and delays. Provide feedback to revenue generating department to accuracy of charges and timely submission. Success in this area will contribute to lower A/R days and improved cash flow in team's area of responsibility, and reduced 'red flag' audits by carriers.
*Outstanding liens are maintained in the commercial team area and reviewed periodically to insure that all liens are released timely upon payment from the patient or insurance company. Liens are scanned to patient account and the original is mailed to the patient upon release recording at the courthouse.
*Prepares productivity reports, which indicate the number of units of work, of various types, completed within a specified time frame. Analyzes and explains substantial increases or decreases in units of work completed. Submits reports to department director on a regular basis.
*Processes auto, workmen's comp and VA pre-billing report. Requests medical records from HIM prior to final bill for work comp and VA accounts, avoid delays in billing. Assures the payers are provided with necessary information and documentation accompanies the claim to the payer. Reviews for obvious errors or missing information to assure claims are not submitted that are certain to return. This greatly reduces write-offs and lost revenue
*Processes patient and insurance correspondence requests, in addition to requests obtained from out-source company, to correct account information, contacts HIM about code inquiries, sends medical records request to HIM, contacts cashier manager to correct payment posting errors and follows up for completion of request. Assures all documents are scanned to account in Valco.
*Provides complete and comprehensive customer service function within its area of responsibility, including responding to patient inquiries and complaints, from all sources, in a timely manner. Initiates necessary corrections to patient accounts, and attempts to repair any damage, which may have been done to patient goodwill. This function requires substantial interaction with other departments, and physician's offices. Success in this area will be indicated by most problems being resolved at team level, with very few concerns reaching the supervisor, department director, patient representative or administration thereby improving our satisfaction scores
*Provides high quality services to all of its customers, which includes, but is not limited to patients, physicians, Case Management HIM, coding other departments, other teams, and third party payers
*Remains constantly alert for process improvement, which could lead to better results within assigned area of responsibility. Recommends changes when it is felt that change would be beneficial. Implements approved changes.
*Responsible for entering Rehab Charges and billing
*Responsible for Higgins Op Plan of Care process and follow up as needed
*Review daily worklist of accounts registered as a result of auto accidents. Contacts patient by phone and/or letter to obtain medical payments coverage information, or applicable third party benefits to cover the benefits to cover the services. If no auto insurance information is updated for the next appropriate insurance or changed to self pay.
*Reviews daily, billing edits and errors identified on failed claims for corrections in Meditech, and errored, rejected claims that require corrections through billing vendor software. All Hospice Blue Cross and Commercial claims are reviewed for correct bill type. seeks resolution to any problem claim to be sure that none go out which are certain to return. Contacts and follows up with departments on issues found that need to be reviewed and/or corrected by the department.
*Reviews insurance payment delays caused by question of primary or secondary payer to Medicare or other commercial insurances. Contacts the patient and/or insurance company to ascertain the correct primary payer and requests cooperation and action from the patient when needed. Contacts the patient by phone or letter assure the patient understands what is needed in order for their claim to be processed by the insurance company of Medicare. Success in this area will contribute to lower A/R days and improved cash flow in the team's area of responsibility.
*Reviews list of claims generated report daily to ensure that all claims have been processed by electronic or paper claim filing. Assures electronic transmission of claims is done on a daily basis through electronic vendor system access and software application. Success in this area will result in quicker turn around in receivable dollars, and less re-work. Directly impacts the departments ability to maintain a 80% or higher clean claims submission percentage.
*Shares the responsibilities of other teams, when there is a need, in a friendly manner. Success in this area will result in the common good of the business office.
*Works closely with case management on inpatient and observation claims denied for no authorization or medical necessity. Utilizes the Midas system to view appeal info and contacts insurance company for status of appeal. Forwards all insurance correspondence relating to denial and appeal to Case Management. Maintains follow-up with insurance company and case management until denial is resolved by payment or adjustment to the account. Success in this area will increase overturn of denials, lower A/R days and improve cash flow.
*Works with the other departments in each facility such as Registration, Physicians offices, Medical Records and Coding/Abstracting in making necessary corrections to charges. Recommends process changes which may reduce the frequently of late or lost charges, or eliminates them reduce the frequency of late or lost charges, or eliminates them altogether. Ensures timely filing and acceptance of claims for prompt payment. This significantly impacts cash flow and AR days.

Compliance Statement
Employee performs within the prescribed limits of Tanner Health System's Ethics and Compliance program. Is responsible to detect, observe, and report compliance variances to their immediate supervisor, the Compliance Officer, or the Hotline.

Education
High School Diploma or GED

Experience
Two years of related experience. Requires working knowledge of specialized practices, equipment, and procedures.

Licenses & Certifications
*NONE REQUIRED

Supervision
*No supervisory responsibilities

Qualifications
*Ability to analyze and prioritize workloads
*Ability to be assertive without being abrasive
*Ability to work closely with others, and function as a team member
*Business like appearance
*Data entry experience in work environment. thirty-five (35) wpm
*Detail orientation
*Good verbal communication skills
*Knowledge and experience with Internet, Word, and Excel
*Proficiency in spelling, business letter writing, and medical terminology
*The ability to understand and work within multiple applications and systems. Both internally and externally
*Two years experience in insurance billing or insurance collections, and patient contact in a hospital, clinic, or physician office. May substitute customer service, teaching, sales, collection, or other occupations, which require control of conversation, heavy detail, and ability to negotiate and compromise when necessary

Definitions
*The Insurance Specialist is responsible for day-to-day processing and follow-up of all insurance Authorizations and precerts, review of trial balances to identify and resolve problem area, formulation of action plans, prioritization of work, and analysis of results and customer service functions. Timely follow up to avoid untimely write offs and significant loss to the organization. Report errors and controllable denials to ensure training and corrections are put in place to reduce exposure to write offs, adjustments and loss of revenue.

Contact With Others
Requires frequent but limited contacts with many others to do job, or extensive contacts with a limited number of categories of people to apply procedures or treatment. Requires discretion and tact to interpret departmental procedures.

Effect Of Error
Probable errors not easily detected and may adversely affect external as well as internal relationships and may result in major expenditures for equipment, materials, or procedures detrimental to the patient?s welfare or the organization?s interest. Work is subject to general review only and requires considerable accuracy and responsibility. Continually works with reports, records, plans, and programs of a major functional area of the organization where integrity is required to safeguard the organization?s position. Duties may involve the preparation of data on which the administration bases important decisions and are highly confidential.

Supervisory Responsibility
Exercises no supervision, work direction, or instruction of other employees or students

Mental Demands
Work involves a variety of complex problems to be solved under general organization policies. Ingenuity and judgment are required to review facts, plan work, estimate costs, and deal with factors not easily evaluated, interpret results, draw conclusions, and take or recommend action. Solutions to problems often require coordination with other departments.

Physical Effort
Moderate physical effort - Lifts, carries, or handles lightweight (1 to 25 lbs.) materials or equipment for about half of the day. Very occasional physical effort with medium weight objects (25- 60 lbs.). Office or laboratory work requires close visual effort and concentration more than half of day. Works in reaching or strained positions for less than half of day.

Working Conditions
Minor - Occasionally involved in exposure to dirt, odors, noise, or some work is performed with exposure to temperature/weather extremes/occupational risk and probability of coming into contact with blood borne pathogens, other potentially infectious diseases, or biomedical/bio-hazardous materials.

Physical Aspects

Continually (at least once per day)
*Hearing
*Visual
*Speaking

Frequently (at least 3 times a week)
*Typing
*Manual Dexterity ? picking, pinching With fingers etc.

Occasionally (at least once a month)
*Reaching ? below shoulder
*Color Vision
*Standing
*Balancing
*Walking
*Running - In response To an emergency
*Lifting up To 25 lbs.
*Handling ? seizing, holding, grasping
*Carrying