The Insurance Billing Specialist is responsible for billing medical claims to insurance and ensuring maximum payment and reimbursement of claims. This position resolves clinic and hospital related claim holds, denials and incorrect billing information. They monitor claim status, filing limits, and policies for Medicare, Medicaid and Commercial plan billing practices. This Insurance Billing Specialist is responsible for all billing for St. Croix Regional Medical Center claims to include Rural Health and Critical Access.
Essential Duties and Responsibilities:
- Process insurance claims
- Expert knowledge of all payer, critical access, rural health, and provider based rules, regulations and billing policies to ensure appropriate processing of claims
- Verify patient eligibility or coverage as needed, both primary and secondary
- Ensure appropriate modifiers are used per payer guidance
- Expert knowledge of revenue codes and appropriate processes and policies for splitting charges (if needed)
- Evaluation if charge splitting is appropriate for service represented on the claim
- Accountable for accurate and timely claim submissions to maintain a steady positive operating cash flow
2. Follow-up on claim denials and follow-up on all unpaid and/or underpaid encounters
- Works billing queues timely
- Analyze, research, and navigate payer specific coverage and reimbursement policies
- Understand and articulate payer specific contracting agreements
- Expert knowledge of payer denial codes
- Accountable to analyze reason for denial and to work towards appropriate resolution
- Expert knowledge of appeal process by payer
- Accountable for biller aging and incoming correspondence timely and appropriate follow-up
3. Identify trends and work towards resolution
- Works with internal departments to optimize charging/billing workflows to ensure maximum automation of clean claims
- Works with system trainer to improve claims processing, work que functionality, and overall efficiency of revenue cycle
- Works with external payer representatives to ensure accuracy of reimbursement
4. Assists patients with billing questions and concerns
- Expert knowledge of all insurance explanation of benefits
- Ability to work with insurance provider and member services to ensure patient understanding
Education & Licensure:
- High school graduate required
- Associates degree in Medical Administration or related field preferred
- Healthcare experience required without secondary degree
Experience:
- Minimum 1-2 years of billing or charge entry experience in healthcare is preferred
- Experience with electronic medical records and billing systems
- Experience in a healthcare business office
Knowledge, Skills & Abilities::
- Intermediate/Advanced computer skills, including but not limited to Microsoft Office products
- Excellent interpersonal, verbal, and written communication skills
- Understanding of Critical Access and Rural Health billing
- Ability to deal effectively and assertively with a broad range of people under varying pressure situations
- Adaptability to constantly changing processes, software systems, and payer programs
- Medical billing background to include knowledge of ANSI codes, CPT, and HCPCS codes, insurance terminology
- Knowledge of insurance billing both UB92/8371 and HCFA 1500/837P claims processing
- High level interpretation and understanding of payer remittance advices in both paper and electronic formats
- Exceptional knowledge of Medicare, Medicaid, HMO, and private payer billing rules and regulations
- Self-motivated, takes ownership in expectations/goals, and sees them through in a timely manner, and seeks supervision appropriately
Physical Requirements:
- Prolonged periods of sitting at a desk and working on a computer.
- Must be able to lift up to 15 pounds at times.
St. Health has been a healing force in the St. Croix Valley for over 103 years. We are a purpose-driven organization with a dedicated team committed to serving our patients and communities throughout the St. Croix Valley. This commitment is rooted in our mission, vision and values.
Mission: We help people live healthier, happier, and longer lives.
Vision: To transform from quality sick care to quality well care that is sustainable and affordable.
Values: People Centered, Trust, Innovation, and Growth.
Here at St. Croix Health we offer our employees with a robust benefits package that includes:
- Health, vision and dental insurance
- 403b retirement program with employer match
- Paid time off
- Short-term disability, long-term disability and life insurance options
- Education reimbursement
- Employee assistance program (EAP)
- Wellbeing incentive program
- Free parking