Claims Specialist

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.
  • Initiate timely appeals for denied claims and follow up on the status of these appeals until resolution.

• Insurance Verification & Follow-up:

  • Verify patient insurance coverage before services are rendered and ensure accurate authorization or pre-certification when required.
  • Follow up on outstanding claims and insurance payments, ensuring timely resolution of unpaid or underpaid claims.

• Documentation & Reporting:

  • Maintain detailed records of claims, including submission dates, payment details, and communications with insurance providers.
  • Prepare regular reports on claim status, aging accounts, denials, and resolutions for internal stakeholders and management.

• Collaboration with Providers and Staff:

  • Collaborate with the healthcare providers to obtain necessary documentation for claim submission (e.g., medical records, treatment notes).
  • Communicate with the MSO's billing and coding team to resolve discrepancies and ensure proper coding of procedures and diagnoses.

• Customer Service:

  • Respond to inquiries from patients regarding insurance claims, billing questions, and any issues related to their medical coverage.
  • Assist patients in understanding their insurance benefits, co-pays, and deductibles.

• Regulatory Compliance:

  • Stay updated on changes in insurance regulations, coding standards, and payer-specific requirements to ensure compliance in all claim submissions.
  • Adhere to HIPAA guidelines and maintain confidentiality of patient information.

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.
  • Familiarity with ENT-specific procedures and coding (e.g., audiology, sinus surgeries, allergy testing) is highly preferred.
  • Experience working with insurance payers, claim management software, and Electronic Health Records (EHR) systems.

• Skills:

  • Strong understanding of medical billing and coding procedures, including CPT, ICD-10, and HCPCS codes.
  • Proficient in Microsoft Office Suite (Excel, Word, Outlook).
  • Detail-oriented with excellent organizational and time-management skills.
  • Strong problem-solving skills with the ability to manage multiple tasks and deadlines.
  • Effective verbal and written communication skills.
  • Ability to work independently and as part of a team.

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