Claims Specialist

Job Description

Job Description

Job Overview :

The Claims Specialist is responsible for managing and processing insurance claims for the ENT (Ear, Nose, and Throat) practices supported by the Managed Services Organization (MSO). This position involves coordinating with healthcare providers, patients, insurance companies, and other stakeholders to ensure accurate and timely claims submissions, follow-ups, and resolution of outstanding payments or denials. The Claims Specialist plays a vital role in maintaining the financial health of the ENT MSO by minimizing claim rejections and ensuring proper reimbursement for services rendered.

Key Responsibilities :

Claims Processing :

Prepare, submit, and track insurance claims for ENT services provided to patients, ensuring all claims are compliant with payer policies and coding standards (CPT, ICD-10, HCPCS).

• Verify the accuracy of insurance information and patient demographics to minimize claim rejections and delays.

Denial Management :

Monitor and manage claim denials or rejections by reviewing the reasons for non-payment and working with the insurance companies and healthcare providers to resolve issues.

Insurance Verification & Follow-up :

Verify patient insurance coverage before services are rendered and ensure accurate authorization or pre-certification when required.

Documentation & Reporting :

Maintain detailed records of claims, including submission dates, payment details, and communications with insurance providers.

Collaboration with Providers and Staff :

Collaborate with the healthcare providers to obtain necessary documentation for claim submission (e.g., medical records, treatment notes).

Customer Service :

Respond to inquiries from patients regarding insurance claims, billing questions, and any issues related to their medical coverage.

Regulatory Compliance :

Stay updated on changes in insurance regulations, coding standards, and payer-specific requirements to ensure compliance in all claim submissions.

Qualifications : Education :

High school diploma or equivalent required; Associate’s or Bachelor’s degree in healthcare administration, business, or a related field preferred.

Experience :

Minimum of 2-3 years of experience in claims processing or medical billing, preferably in the healthcare industry or a specialized medical field like ENT.

Skills :

Strong understanding of medical billing and coding procedures, including CPT, ICD-10, and HCPCS codes.

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