Insurance Specialist

Role Overview

• Review and analyze delayed or denied claims to determine root cause based on payer explanation of benefits (EOB) or remittance advice.
• Conduct timely follow up with insurance carriers to clarify claim status, resolve issues, and secure payment.
• Obtain missing information, correct coding or billing errors, and submit corrected claims or resubmissions when appropriate.
• Escalate unresolved or complex claims to Appeal Specialists or management as needed.
• Research and interpret payer coverage policies, contracts, and medical necessity requirements related to molecular and NGS testing.
• Stay current on payer-specific guidelines to ensure accurate claim resolution and resubmission.
• Document all follow up activity, payer communication, and resolution steps accurately and timely within the billing system.
• Ensure all work complies with HIPAA, payer rules, and internal company policies.
• Partner closely with prior authorization, billing, reimbursement, and client services teams to gather required demographic, coding, or clinical documentation.
• Communicate with providers and internal stakeholders to resolve claim discrepancies or obtain additional information.
• Track claim statuses, denial reasons, resolution timelines, and follow up outcomes.
• Identify denial and delay trends and collaborate with leadership to implement strategies to reduce future denials.
• Provide feedback on workflow opportunities and process improvements to enhance revenue cycle efficiency.
• Manage incoming single-case agreements or LOAs and negotiate appropriate reimbursement rates.
• Provide trends of single case agreements to contracting and payer relations teams.
• All other duties as assigned.

Requirements

• High school diploma.
• 2 years of experience in insurance follow up, denial management, medical billing, or revenue cycle operations.
• Strong knowledge of insurance billing processes, denial codes, and payer follow up workflows.
• Excellent verbal and written communication skills.
• Strong problem solving and analytical abilities.
• Proficiency with billing systems and Microsoft Office Suite.
• Detail oriented with strong organizational skills.
• Ability to manage multiple priorities independently in a fast-paced environment.
• Critical thinker with a proactive approach to issue resolution.
• Associate or bachelor’s degree preferred.
• Experience with molecular/genetic testing or specialty laboratory billing.
• Experience using Quadax or similar RCM systems.

Benefits

• equity grant
• bonus eligible