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

Job Description

Insurance Specialist I

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 Physicians. This position requires knowledge of Federal, State, and payor regulations, reimbursement methodologies; and communication with third party payors to facilitate timely and accurate reimbursement. Employees will be working on Insurance Follow-Up projects and placing calls to insurance payers. Must be able to multitask and use knowledge of insurance, workers comp, MVA, CPT Codes and ICD10 Codes to reprocess claims and manage patient's accounts. Monthly quota must be met.

*REMOTE POSITION - CANDIDATES MUST RESIDE IN FL - PREFERABLY IMMEDIATE TAMPA BAY REGION*

Work Style/Location

• While onsite support may be required occasionally, this position will permanently report to a remote/work at home office.

Required Equipment for Remote Workforce

• Minimum internet hardwired internet speed of 100m x 1m (Satellite, Wireless and or Hot Spot service are prohibited)
• A dedicated secure home workspace for interview and for work purposes.
• Acknowledgement and Compliance with all aspects of the Remote Workforce Agreement
• Employee must provide all necessary computer equipment with the exception of the following which will be provided to them:
  • One Monitor
  • Webcam
  • Connection Cables

Essential Functions of the Position:

• Run and/or work various reports as instructed, including:
• Summary Aging Report
• Detailed Aging Report
• AR Spreadsheet
• Denial Work List / Spreadsheet
• Unbilled Items Report

• Run and/or work Aging Reports Monthly/Claim Control Work Queue Filters:
• Maintain AR over 90 days at or less than 9%
• Work all accounts aged 30 days and greater by Insurance/Provider.
• 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.
• Identify any claims that have denied and contact the carrier as necessary. All denials should be appropriately resolved, and appealed only if warranted.
• Resubmit any corrected claims for reimbursement, utilizing electronic methods when available.
• Run and/or work Denial Work List (as supplement to claims control work queues):
• Task the office for denials related to no authorization, and Coding Dept for denials related to 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.
• Run and work Unbilled Items report weekly:
• Review any claims/charges that are unbilled due to being placed on either ailment or task hold
• Follow up on any tasks/communications with office staff in regards to charges on hold (missing authorizations/number of units/ NDC# etc.)
• Prepare for Monthly Divisional Meetings
• Maintain a list of trends for review with Supervisor during one on one meeting, including trends found while journal scrubbing and working denial and AR reports.
• 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.

• Quality and Quantity of work
• 97% or better audit scores (timeliness of follow up, appropriate account notes, procedures followed etc.)
• Meet expectations for number of accounts worked daily for assigned specialty.
• Work mail daily, Unbilled Items Report weekly, Denial Reports weekly, AR Reports monthly.
• Work all adjustments up to approved level. Any adjustments above approved level must have prior approval from the Supervisor.
• Write up refunds requests from Insurance carriers that do not recoup.
• Job Knowledge/Contractual Reimbursement:
• Knowledge of contractual reimbursement per specialty and payer.
• 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 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, and private work area.
• Proper phone etiquette.
• Quantity and quality of work overall meets department expectations.
• Adheres 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.
• Maintaining a positive and professional attitude.
• Able to handle stressful situations.
• Able to meet deadlines.

Job Qualifications:

• Graduate of Health Insurance Specialist Certificate or Degree program preferred OR High School Diploma. Bachelors preferred. Two years of experience in health care insurance
• Minimum two years billing, insurance follow-up, and denials management experience – appeals.
• Expert working knowledge of EOB's, copay/coinsurance/deductibles, denial codes, insurance allowable, adjustments, write offs, understanding of managed care contracts, denials and payer methodology.
• Expert knowledge of UB and 1500 claim forms
• Strong knowledge of Medicare, Medicaid, United, Aetna, Humana, BCBS, Workers' Comp and MVA payer and billing policies
• Expert knowledge of CPT/HCPCS and ICD-10 codes
• Knowledge of charge posting and EDI functions preferred
• Ability to navigate different computer systems
• 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 daily quota
• 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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