Medical Insurance Representative (U) (4581.1)

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 payor. The incumbent routinely reviews outstanding invoices to determine action steps needed to resolve the balance. This is an entry level position which functions in a training capacity under direct supervision processing routine, non-complex medical/health claims.

75% Invoice Follow-up:

• Reviews Explanation Of Benefits (EOB) for denials
• Access patient account in the GE 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.
• Request appropriate adjustment/write off for denied charges that do not need medical coding review (non-covered service, untimely filings, etc.)
• Retrieves EOB's from CD rom, microfilm or other hard copy records and files as needed.
• Make appropriate entry of actions taken in the billing system modules.

10% Insurance Follow-up:

• Contact Insurance company representatives to discuss denials and zero pays.
• If easily resolved, 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.

12% Correspondence:

Opens and reviews incoming mail related to the payer teams. Responds to routine correspondence as needed.

3% Other duties as assigned

Qualifications:

• High school diploma or equivalent.
• Any one or combination totaling six (6) months from the categories below: 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 six (6) months. Work experience in a healthcare environment working with medical claims, denials, rejections, referrals, and/or prior authorization.