Insurance Specialist - Accounts Receivable - Florida Medical Clinic

Our Vision is to be the best choice for healthcare in our community

Job Description

Insurance Specialist  - Accounts Receivable 

**Remote - MUST RESIDE IN FL, GA OR TN**

Reports to:  CBO Supervisor

Department:   CBO 

Job Summary: The Insurance Follow-Up Specialist I is responsible for accounts receivable through claim follow up, cash collection, and denial management for services rendered by Florida Medical Clinic providers. This position requires knowledge of Federal, State, and payor regulations/guidelines, reimbursement methodologies; and communication with third party payors to facilitate timely and accurate reimbursement. Employees are responsible for insurance follow-up including denial disputes, written appeals, projects, on-line research, and/or phone calls. Must be able to multitask. Daily/Weekly/Monthly productivity quotas must be met.

Essential Functions of the Position: 

Run and/or work various reports/ work queues as instructed, including:

• Summary/Detailed Aging Reports (As Requested)
• Claim Control Work Queue Filters (Daily)
• Tasks (Daily)
• Mail (Daily)
• Denial Work Lists / AR Excel Spreadsheets (provided as a supplement to Claims Control work queues when necessary)
• Unbilled Items report (Weekly)

Prepare for Monthly Divisional Meetings

• Maintain a list of trends for review with Supervisor during one on one meeting, including trends found while working denial/AR reports and Claims Control.
• Urgent issues/trends should be brought to Supervisor's attention immediately.
• Escalate any accounts that are problematic and difficult to obtain payment in a timely manner to Supervisor/TL. 

Quality and Quantity of work

• Maintain AR aged over 90 days at or less than 9%
  • Work all accounts aged 30 days and greater by Insurance/Provider every 45 days.
  • 95% or better audit scores (timeliness of follow up, proper procedures/resolution efforts followed etc.)
  • Meet expectations for number of accounts worked daily/weekly/monthly for assigned specialty.
  • Contact Insurance carriers to obtain claim status /confirm claims are on file and in process to pay.
  • Review explanation of benefits to ensure the claims have processed per our contractual agreement.    
  • Ability to research and review payor coverage guidelines.  
    • Identify any claims that have denied and perform resolution research as necessary. All denials should be appropriately resolved in a timely manner, and appealed only if warranted.  
  • Resubmit any corrected claims for reimbursement, utilizing electronic methods when available.   
  • Use proper filtering techniques to ensure high dollar and oldest claims are worked as a priority to avoid untimely follow-up, in addition to grouping similar denials in order to work in an efficient and organized manner.
  • Task the office for denials related to no authorization, and Coding Dept for denials related to medical necessity, diagnosis/CPT conflicts, etc.
  • Review and work all clinical tasks within 2 business days.
  • Any Insurance denial trends should be brought to the attention of the Supervisor/TL. 
  • Review any claims/charges that are unbilled due to being placed on either ailment or task hold to ensure resolution in order to file claims in a timely manner.
  • Follow up on any tasks/communications with office staff in regards to charges on hold (missing authorizations/number of units/ NDC# etc.) 
  • Work all adjustments up to approved level. Any adjustments above approved level must have prior approval from the Supervisor.
  • Initiate refunds to insurance carriers and patients as they are identified by filling out appropriate forms.

Job Knowledge/Contractual Reimbursement:                        

• Knowledge of contractual reimbursement per specialty and payor.
• Review CCI/CPT for correct billing.
• Understand site of service differentials
• Understand when multiple procedure payment reductions apply.
• Identify underpaid/overpaid claims                        

 Additional Responsibilities: 

• Access Claims Tracker.
• Utilize the Internet and various websites for multiple job requirements.
• Contact patients for additional information when necessary.
• Utilize Fax System when necessary
• Basic Excel knowledge
• Email
• DocuPhase
• Microsoft Teams

General:

• Maintain an organized, clean, quiet, and private work area.
• Use proper phone/messaging etiquette.
• Quantity and quality of work overall meets department expectations.
• Adhere to FMC and CBO policies and procedures 

Physical and Mental Demands:

• Normal physical ability to sit for long periods of time while on the phone/computer.
• Maintaining a positive and professional attitude.
• Able to handle stressful situations.
• Able to meet deadlines. 
• Self-motivated and able to work independently

Job Qualifications:

• Graduate of Health Insurance Specialist Certificate preferred OR High School Diploma.
• Minimum two years medical/professional billing, insurance follow-up, and denials management experience – appeals.
• Expert working knowledge of EOB's, copay/co-insurance/deductibles, denial codes/reasons, insurance allowables, adjustments, and an understanding of payor reimbursement methodologies and guidelines.
• Expert knowledge of HCFA 1500 and/or UB04 claim forms
• Strong knowledge of major payor billing policies, including: Medicare, Medicaid, Aetna, BCBS, Cigna, Humana, Untied Healthcare, Workers' Comp and MVA.
• Expert knowledge of CPT/HCPCS and ICD-10 codes
• Knowledge of charge posting and EDI functions preferred
• Ability to navigate payer websites/portals and other various sites to conduct research
• Accounting Principles, Basic Office Skills required; advanced office skills are preferred.
• Strong communication skills (oral and written); must be able to collaborate effectively and work in a team environment
• Ability to work at a fast pace - meet productivity quotas while maintaining a high level of quality in work performed
• Detail oriented with excellent organization skills
• Ability to multitask and effectively manage numerous competing priorities
• Excellent phone skills

We are an Equal Opportunity Employer and make employment decisions without regard to race, gender, disability or protected veteran status

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