"Medical Insurance Associate (U) (4582.1)"

The function of this position examines and analyzes explanation of benefits to determine if correct payment has been made or to determine how to receive maximum benefits from the third party payer. The incumbent routinely reviews outstanding invoices to determine action steps needed to resolve the balance.

Invoice Follow-up: 70%

• Reviews explanation of benefits (eob) for denials
• Access patient account in the Athena billing system.
• Determine action needed and proceed appropriately.
• Bill secondary insurance when appropriate.
• Transfer denied charge to patient or another responsible party as needed.
• Order medical notes when needed.
• Submit denial information to the medical coding staff in the clinical departments for review and coding decisions. Track requests for coding review. Resubmit claims based on the coding reviewer response or take write-offs as directed.
• Review charges that are paid to determine if further review is necessary.
• Process appropriate adjustment/write off for denied charges that do not need medical coding review (non-covered service, untimely filings, etc.)
• Retrieves eobs from hard copy records and files as needed.
• Make appropriate entry of actions taken in the billing system modules.
• Open, print and close batch proof; balance after daily use.

Insurance Follow-up: 15%

• Contact Insurance company representatives to discuss denials and zero pays.
• Able to make complex decisions when resolving accounts, take appropriate action steps including resubmission, adjustments, request for review, etc.
• Forward to immediate supervisor or manager if necessary.
• Request telephone reviews of claims if appropriate.
• Make appropriate entry of actions taken in the billing system modules.

Correspondence: 10%

• Opens and reviews incoming mail related to the payer team. Responds to complex correspondence as needed or as instructed by the Insurance Assistant Manager.

Other duties as assigned: 5%

Any one or combination totaling one (1) year (12 months) from the categories below:

1. College coursework in a health-related field, business administration/management, human resource management, or closely related fields as measured by the following conversion table or its proportional equivalent:

• 30 semester hours equals one (1) year (12 months)
• Associate's Degree (60 semester hours) equals eighteen months (18 months)

1. Work experience in a healthcare environment working with medical claims, denials, rejections, referrals, and prior authorizations.