Senior Insurance Claims Specialist

Role Overview

• Review and process all BC/BS and Commercial high dollar claims (over $10,000) for denials, payor issues and payment trends.
• Submit, process and track all appeals for BC/BS and commercial payors. Maintain knowledge of ERISA laws governing employee benefit plans and manage the appeal process for these claims.
• Assist A/R staff with complex claim issues they are unable to resolve in a timely manner.
• Track and trend all Single Case Agreements. Work closely with Contracting on any SCA payment issues / concerns.
• Review payments for BC/BS and commercial payors for rate validation according to our contracts.
• Track all denial outcomes for payment, write-offs and transfers to client liability. Identify the root cause for the adjustments to client accounts. Work with management to review adjustment trends and identify potential solutions.
• Help maintain integrity of accounts receivable ledger, including aged receivable monitoring on an ongoing basis.
• Responsible for maintaining current knowledge of revenue components including benefit plans, contract terms and rates and billing forms and codes.
• Check status of claims through use of telephone, websites and/or other means available.
• Document adjustments needed to patient accounts.
• As needed, participate in phone conference calls with payors.
• Pursue collection activities and follow up for balances outside of established norms.
• Coordinate collection activities with outside agencies, including court appearances, as needed.
• Provide feedback & education management with regards to issues that impact revenue flow.
• Provide appropriate documentation and reports designed to assist in fiscal management of the agency.
• Serve as a member of the SWAT Team and participate in team meetings.
• Serve as a member of the Revenue Cycle Team and participate in all team meetings and activities.
• Understand and comply with all of the principles established by the Rosecrance Corporate Compliance Program and Code of Ethics.
• Perform all responsibilities in compliance with the mission, vision, values and expectations of Rosecrance.
• Deliver exceptional customer service consistently to every customer.
• Serve as a role model for other staff, clients and customers and demonstrate positive guest relations in representing Rosecrance.
• Assume other related responsibilities as assigned by management.

Requirements

• High School diploma or GED
• Minimum of ten years’ experience in researching and solving high dollar complex insurance claims and denials.
• Computer proficiency in a Windows environment, knowledge of Microsoft Office products with an emphasis in Excel.
• Adequate written skills to accurately complete required documentation within the time frames prescribed
• Excellent organizational and customer service skills
• Must be emotionally and medically able to perform essential job responsibilities
• Must be free from active or infectious diseases

Benefits

• Medical, dental, and vision insurance (multiple plan options to meet your needs)
• 401(k) with employer match & discretionary contribution
• Group Life Insurance, LTD and AD&D
• Tuition assistance & licensure/certification reimbursement
• Paid Time Off, sick time, bereavement leave
• Referral program earning up to $1,000 per hire!
• Wellness program, including an on-site gym at select facilities
• Discounts at participating retailers
• Daily pay available through UKG Wallet for financial flexibility