Insurance Processing and Denials Specialist

Insurance Processing and Denials Specialist

Department: Revenue Cycle

Program: Health Systems

Reports To: Central Business Office Supervisor

Employment Status: Full-Time

FLSA Status: Non-Exempt

Schedule: 40 Hours/52 Weeks

Preference: TERO Ordinance 2017-01, P.L. 93-638

Job Summary

The Insurance Processing and Denials Specialist performs financial, clerical, reporting, and administrative duties necessary to ensure efficient, timely, and accurate payment of Health Systems Department accounts. The Insurance Processing and Denials Specialist will utilize the electronic health records to review and satisfy billing edits, charge information, private or government insurance benefits, and other related information. The Insurance Processing and Denials Specialist will review and process all denials for all Health Systems Departments in accordance with best practices.

Essential Functions

• Completes cash and charge reconciliations, post-payment reviews, and denial management for all Health Systems Departments
• Prepares and submits appeals to insurance companies
• Verifies outgoing electronic claims are transmitted successfully
• Enters insurance posting adjustments into correct system
• Reviews denials for entire claim or line items and process appropriately
• Identifies recurring billing errors and trends and report to Central Business Office Supervisor
• Provides monthly report to supervisor on all denials
• Ensures compliance with Tribal, federal, state, and local employment laws and regulations, Tribal policies and TERO ordinance
• Review payor communications and prior authorization requirements to identify risks and potential loss of reimbursements

It is the intent of this job description to highlight the essential functions of the position; however, it is not an all-inclusive list. The incumbent may be called upon and required to follow or perform other duties and tasks requested by his/her supervisor, consistent with the purpose of the position, department and/or the Kenaitze Indian Tribe's objectives.

Working Conditions

Lifting Requirements

• Light work - Exerting up to 20 pounds of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg control requires exertion of forces greater than that of sedentary work and if the worker sits most of the time, the job is considered light work.

Physical Requirements

• Stand or Sit (Stationary position)
• Walk (Move, Traverse)
• Use hands/fingers to handle or feel (Operate, Activate, Use, Prepare, Inspect, Place, Detect, Position)
• Talk/hear (Communicate, Detect, Converse with, Discern, Convey, Express oneself, Exchange information)
• See (Detect, Determine, Perceive, Identify, Recognize, Judge, Observe, Inspect, Estimate, Assess)
• Repetitive Motion

OSHA Categories

• Category III - Normal routine involves no exposure to blood, body fluid or tissue and as part of their employment, incumbents are not called upon to perform or assist in emergency care or first aid

Equipment and Tools

Equipment used for job: Computer, phone, scanner, copier, electronic health records

Travel

• Local
• In-State

Qualifications

Education

• High School Diploma or GED

Experience

• Two (2) years processing insurance claims and/or healthcare insurance denials management

Preferred

• Knowledge and experience working with cultural diversities
• Certified Professional Coder (CPC)
• Associates degree in related field
• Experience with Indian Health Services facilities operations

Special Skills

• Proficiency with Microsoft Suite, or obtain training within 90 days of hire
• Conducts business in a service-oriented manner that is attentive, pleasant, respectful and kind when dealing with un'ina, visitors, co-workers and others
• Ability to multi-task, work independently, and meet deadlines
• Understanding of insurance policies, coverage requirements and payer-specific billing guidelines
• Knowledge of billing and coding for Primary Care, Dental, Optometry, Laboratory, Therapy Services, Radiology, Pharmacy, Behavioral Health, etc.
• Proficiency in processing insurance claims from submission to follow-up, including knowledge of claim forms, and handling various types of claims
• Skilled in analyzing and resolving claim denials, filing appeals, and understanding denial codes and reasons to ensure timely and accurate reimbursements
• Competency in medical coding systems to accurately code services and procedures for claims processing
• High attention to detail for reviewing insurance claims and billing statements, ensuring accuracy and completeness to avoid errors and rejections
• Familiarity with healthcare billing regulations, including HIPAA and guidelines for medical necessity and compliance with payer requirements
• Ability to identify billing and insurance issues and apply solutions to improve claim approval rates
• General knowledge of medical terminology

This position is a Covered Position subject to all requirements of the Alaska Barrier Crimes Act (ABCA) and to the Indian Child Protection and Family Violence Prevention Act, (ICPA). ABCA and ICPA requirements apply and must be complied with at all times in order to remain in the position.

• Memorandum of Understanding: Serves as documented evidence that the Kenaitze Indian Tribe has expressed the ineligibility of an employee to operate motor vehicles owned, leased or rented by the Kenaitze Indian Tribe, or to operate a personal vehicle on behalf of the Kenaitze Indian Tribe.