Title: Claim Specialist Department: Central Business OfficeFLSA Status: Non-Exempt Reports to: CBO SupervisorJob Number: Approved/Revised Date:About Wilmington HealthSince 1971, Wilmington Health has been committed to the care and health of our community in Wilmington as well as all of Southeastern North Carolina. Wilmington Health is structured as a multi-specialty medical practice with primary care providers integrated into the system. In this way, Wilmington Health is able to provide a comprehensive and coordinated approach to the care of all our patients. Wilmington Health is committed to using collaborative, evidence-based medicine in providing the highest quality of care to the patients we serve.PurposeEnsures claims are received by the correct payer in an accurate and timely manner.Essential Duties/ResponsibilitiesResearch and resolve claim edits generated in billing system and clearinghouse, as assignedResearch and resolve first-level denials, as assignedVerify Medicaid eligibility for hospital-based services provided to uninsured patientsResearch and confirm contracted status of minor insurance plans, document findings as a resource for others; follow established protocol to notify the patient of findings, explain financial responsibility for future appointments; work with System Build Team to activate or deactivate plans as neededUpdate insurance information on patient account as appropriate; take action on previous dates of service as neededCorrespond to carrier for such things as appeals and or inquiries, within carrier timely filing guidelines and following carrier’s published protocolsCommunicate all insurance regulation changes to supervisor, providers and other departments as appropriateContact carrier and or patient to follow-up on denials and termination of coverageRespond to telephone calls, review and respond to correspondence in a timely mannerWork with Coder Team regarding appropriate code changes for effective appealsCommunicate trends to supervisor to assist in pro-active training and protocolsOther DutiesAs assigned by managerQualificationsRequired:High school diploma or general education degree (GED)3-5 years' experience in a medical office environment or equivalent combination of education and experienceFull COVID 19 vaccination is required as a condition of employment for all positions with Wilmington Health. Documentation is required prior to orientation.Wilmington Health is an Equal Opportunity Employer committed to providing equal opportunities to all applicants and employees. We are committed to treating everyone equally and with respect regardless of race, age, sex, religion, national origin, citizenship, marital status, veteran’s status, sexual preference, disability, genetic information, or any other class protected under state or federal law.ADA Physical DemandsRarely (Less than .5 hrs/day) Occasionally (0.6 – 2.5 hrs/day) Frequently (2.6 – 5.5 hrs/day) Continuously (5.6 – 8.0 hrs/day)Physical DemandRequired?FrequencyStandingOccasionallySittingContinuouslyWalkingOccasionallyKneeling/CrouchingRarelyLiftingRarelyClaim Specialist CompetenciesGeneral

• Customer Service
• Professionalism/Integrity/Responsibility
• Teamwork/Process Focus
• Dependability/Punctuality
• Interpersonal Relationships/Communication
• Judgment/Decision Making/Problem Solving
• Quality/Quantity
• Initiative
• Safety/Housekeeping
• Organizational Skills/Time Management

Department Specific

• Decision-making skills regarding ‘next step’ when working edits, rejections and denials
• Resourceful in finding appropriate information to assist in resolving the issue at hand
• Up-to-date with carrier changes as well as specialty-specific changes
• Effectively communicate changes to departments and co-workers
• Use all available tools and resources to accomplish job duties in an efficient and timely manner
• Strong computer skills, i.e., Windows environment, word processing, spreadsheets, etc.
• Effective use of software and web-based carrier sites for submission of claim and requested documentation
• Reliable source of information in regards to assigned carrier rules and requirements
• 2-3 years of experience in medical billing, specifically with claims edits, eligibility, level 1 claims denials.