The Claim Specialist’s main focus is to obtain maximum and appropriate reimbursement for all claims from government and third party payers. The Claims Specialist is responsible for preparing and submitting timely and accurate insurance claims to government and third party payers, assisting in the implementation of payer regulations and ensuring compliance to the regulatory requirements, and verifying payments and adjustments are appropriately applied to accounts based on government, contract or other regulations or agreements. The Claims Specialist is responsible for appropriate follow up on all accounts pending payment from government and third party payers.

Essential Job Functions

• Supports and models behaviors consistent with the mission and philosophy of Billings Clinic and department/service.
• Responsible for submission of timely and accurate claims to primary, secondary, and tertiary insurances for both electronic and paper submission. Generates telephone calls to insurance carriers to follow up on insurance using reports generated for this purpose to ensure the timely collection of money due on the account.
• Audits accounts by verifying that reimbursement amounts are appropriate, coordination of refunds, if appropriate, and coordinating adjustments when necessary, claims appeals or resubmissions, moving balances from insurance responsibility to patient responsibility when appropriate, and reviews and resolves credit balances.
• Ensure that claims have appropriate information on them for submission to insurance companies or agencies by reviewing errors and other prebilling insurance reports/worklists. Analyzes and review claims to ensure that payer specific regulations and requirements are met.
• Prepares and presents verbally and in writing challenges to third party payers for additional reimbursement for denied charges and/or reductions in reimbursement as appropriate.
• Provides guidance and or assistance to the cashiers.
• Provides timely follow-up on correspondence received from the insurance carrier or patient.
• Responds to inquiries from customers/other departments/insurance carriers regarding insurance coverage issues, coordination of benefits, reconciliation of account balances and complaints regarding services received. Initiates appropriate follow-up on outstanding issues.
• Sets up registration and insurance information when necessary.
• Utilizes performance improvement principles to assess and improve quality.
• Identifies needs and sets goals for own growth and development; meets all mandatory organizational and departmental requirements.
• Maintains competency in all organizational, departmental and outside agency environmental, employee or patient safety standards relevant to job performance.
• Performs other duties as assigned or needed to meet the needs of the department/organization.