INSURANCE ACCOUNT REPRESENTATIVE- CENTRAL BILLING OFFICE

Summary

The Insurance Account Representative follows up on unpaid insurance claims according to the balance and age, resolves carrier denials and requests for further information, reviews medical records to select appropriate CPT and ICD codes for payment, adheres to Federal and carrier rules and regulations for billing to ensure compliance, and maintains knowledge of specific carrier guidelines to obtain optimum payment. 

Essential Duties and Responsibilities

• Reviews claims denials from third party carriers in accordance with the Insurance Follow-up Policy.
• Verifies the completeness and accuracy of coding.  Ensures compliance with HCFA’s billing guidelines.  Use resources such as the CPT, ICD-9, ICD-10 and HCPCS coding books, provider manuals, Medicare’s Correct Coding Initiative, subscriptions and publications to support correct coding.
• Follows up on unpaid third party carrier claims according to the balance and age of the charges.
• Contacts insurance carriers to verify the status of claims and resolve processing problems.
• Ensures that proper documentation accompanies claims when appropriate such as operative notes, progress notes, consent forms, referral forms and primary EOB’s.
• Transfers unpaid insurance balances to the guarantor in accordance with the Insurance Follow-Up Policy.
• Handles patient calls and assists them in resolving unpaid third party claims.
• Appeals claim denials as justified.
• Maintains knowledge of third party carrier filing requirements to include timely filing limitations.
• Identifies problem payers and reports them to the Central Billing Office Manager.
• Documents all insurance follow-up activity in Group Management.
• Writes a Request for Refund when noting one is necessary.  Forwards the request to the Central Billing Office Manager.
• Balances all postings to IDX daily.

Other

• Compiles information and prepares reports.
• Maintains records.
• Participates in educational activities. 
• Regular and in-person attendance as scheduled and required to perform essential job functions.
• Follows organizational policies and procedures, including State of Franklin Healthcare Associates Compliance Manual, Code of Ethics and Business Standards, HR Policies and Procedures Manual, Team Member Handbook, OSHA Manual and any other policies or procedures for the job function, department, location or clinic.
• Performs other duties as assigned.

Direct Reports

None

Qualifications

Knowledge of medical billing and collection practices, knowledge of medical terminology, ICD-9, ICD-10 and CPT coding, insurance agency operating procedures and practices, and governmental legal and regulatory provisions related to billing and documentation. Skill in using computer, calculator, copy and fax machine.   

Education

High School Diploma or GED

Experience

Two years of insurance billing and follow-up experience in the medical field or additional related education may be substituted for the two years of insurance experience.

Certificates, Licenses, Registrations

None

Competencies

Service: Demonstrates high standards of service to patients, physicians, team members and other departments; remains calm when faced with challenging or difficult situations; effectively resolves service issues.

Quality: Work is thorough and accurate; offers ideas and solutions to improve outcomes and enhance service; considers the situation and relevant information before taking action; effectively implements improvements.

Integrity: Acts with the highest levels of personal ethics, honesty and accountability.

Performance: Applies job specific knowledge, skills and experience to accomplish results; requires appropriate level of supervision; work is completed in a timely manner; uses sound judgement in decision-making; is reliable and dependable; utilizes time and resources responsibly; complies with policies and procedures; work area is organized, neat and clean.

Communication: Expresses facts and ideas in a clear, convincing and organized manner; listens effectively; professional, respectful and compassionate in communications with others; follows proper channels of communication and shares essential information timely; maintains appropriate confidentiality.

Teamwork: Builds and maintains effective working relationships; recognizes strengths and contribution of others; manages and resolves conflicts in a positive and constructive manner.

Working Conditions

Work is performed in a medical office environment involving contact with patients, physicians, staff, insurance carriers and other business partners.  Occasional local travel between work sites and additional hours, including evening or weekend work, may be necessary.

Physical Requirements