Job Title: Insurance Representative Reports To: Private Insurance Supervisor
Department: Insurance/Private Pay Location: Patient Business Services
FLSA Status: Non-Exempt
The Insurance Representative is responsible for the follow-up on all private pay and commercial insurance claims. The incumbent will resolve unpaid accounts in a timely and efficient manner for one or more geographical areas, while maintaining quality and productivity standards set for the Insurance Representative
Essential Duties and Responsibilities:
- Review, modify as necessary, and re-bill rejected/denied claims in “queue” by assigning appropriate insurance carrier, utilizing the billing address and/or payor prefix.
- Process “queues” within appropriate timeframes, (e.g. claims status checks, appeals of denied claims).
- Recode private pay, commercial insurance and HMO claims, assigning proper condition codes/ICD-9 codes/procedure codes into the Accounts Receivable Billing System and re-file claims as necessary.
- Update appropriate modifiers, based on origin and destination of trip and change insurance claims as necessary.
- Create narrative in the Accounts Receivable Billing System to document status of trip for use in claim appeal process.
- Ensure that charges are billable to a particular commercial payor, based on the payor’s criteria, as needed.
- Resolve payment issues with carriers, (e.g. denials, partial payments, etc).
- Appeal claims as necessary.
- Process daily claims reports, (e.g. “Collection Plan Audit”, “Unpaid Claims”, “CSR Queues”).
- Process incoming correspondence, including signature letters, denials and additional information necessary to release the claim.
- Forward all credit card payments to Cash Posting when identified in Patient Care Report (PCR), correspondence and/or Computer Aided Dispatch (CAD) notes.
- Determine the Level of Service to be billed, based on supporting documentation on the PCR and/or in the CAD notes, including but not limited to, designating Advanced Life Support (ALS), Basic Life Support (BLS), Wheelchair, or Specialty Care Transport (SCT)/Critical Care Transport (CCT).
- Review clearinghouse transmission listings and in-house error logs, make appropriate corrections.
- Resolve incoming calls from carriers, providers and patients.
- Adjust Patient Accounts based on court instructions, due to bankruptcy proceedings, as required.
- File claims for deceased patients, against estates, as required.
- Process “Very Important Person” (VIP) transports by verifying information with Human Resources and adjusting the account accordingly as required.
- Adhere to all company policies and procedures.
- Adhere to and comply with information systems security. Know and follow Information Systems security policies and procedures. Attend Information Systems security training, when offered. Report information systems security problems.
Non-Essential Duties and Responsibilities:
- Work in a spirit of teamwork and cooperation.
- Convey a sense of competence and commitment.
- Use initiative to learn new skills, enhance personal knowledge and improve communications.
- Demonstrate an ability to work well with team members.
- Communicate a willingness to help others succeed.
- Share workspace and resources as necessary.
- Perform other duties as required.
Education/Licensing/Certification: High School Diploma or GED required; Associates Degree or certificate of completion from a coding and billing school preferred. Must pass new-hire and department-specific testing.
Experience: Minimum one (1) year previous medical billing experience or related office work experience required, ambulance billing experience preferred.
Knowledge and Skills:
- Medical transportation processes.
- Terminology on a PCR, Hospital Face Sheet, and/or a CAD Sheet.
- Process of signature and paperwork compliance.
- Payor-specific requirements for one or more geographical areas and/ or financial classes.
- Distinctions between ALS/BLS/SCT/Gurney/Wheelchair/CCT levels of service.
- ICD-9 coding/condition codes and procedure codes.
- Insurance carrier coverage guidelines, filing limits and necessary prior authorizations
- Medical terminology and insurance terminology
- Appeal process
- HIPAA requirements
- Pass new-hire and department-specific testing, (e.g. data entry test and department-specific aptitude testing).
- Flexible with shifting daily priorities.
- Meet deadlines working within tight time constraints
- Handle a large volume of work and/or phone calls.
- Recognize improper fee schedules
- Identify non-payment issues by carrier and claim and to escalate to Management as necessary
- Recognize overpayments and request refunds as necessary.
- Prioritize workflow.
- Process clean claims for one or more geographical areas and/ or financial classes.
- Meet or exceed and sustain all established standards for productivity and quality.
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