Sr Insurance and Claims Specialist

Nature and Scope

The Senior Insurance and Claims Specialist is responsible for optimizing the system to ensure accurate claim submission and follow-up, resulting in timely reimbursement per payor and regulatory guidelines. This includes:

• Completing detailed appeals of denial or payment variance to payors, incorporating contract terms, clinical or regulatory justification for reconsideration or additional reimbursement.
• Recommend system changes for clean claim submission to aid in the prevention of denials.
• Working with the Renown Contracting Department or payor representatives to resolve billing issues due to payor or regulatory changes affecting the billing of healthcare claims.
• Assisting with testing and troubleshooting of systems for payor or regulatory changes.
• Maintaining expertise for all payor, HIPAA, and other regulatory changes affecting the billing of healthcare claims.
• Working hand in hand with Operations Analysts and Information Technology to maintain and improve business system changes based on payor or regulatory changes.
• Acting as a resource for staff on all areas relating to edits and denial/rejection resolution.
• Identifying trends in payor non-compliance and informing management if unable to resolve with payor.

Minimum Qualifications

• Education: Ability to read, write, speak, and understand English sufficiently to perform job duties safely and effectively.
• Experience: Two years healthcare billing office experience with extensive knowledge of healthcare billing, government and third-party payor requirements.
• Computer / Typing: Proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel, Teams, and Word, and the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.