Schedule: FT, Mon - Fri 8:00 - 5:00 (hybrid - in office 2 days a week)
At Children’s Nebraska, our mission is to improve the life of every child through exceptional care, advocacy, research and education. As the state’s only full-service pediatric healthcare center, we provide comprehensive, holistic care to our patients and families—from primary and specialty care to behavioral health services and everything in between. Dedicated to a People First culture, we foster an environment with joy, belonging, wellbeing, learning and growth. Turn your passion into purpose and make a difference where it matters most.
A Brief Overview
The Sr. Insurance Follow-up & Denial Specialist is responsible for corresponding with commercial and government health insurance payers to address and resolve outstanding insurance balances and denials in accordance with established standards, guidelines and requirements. Identifies and analyzes underpayments to determine the reasons for discrepancies, root cause and processes appeals and reconsiderations. Conducts follow-up process activities through phone calls, online processing, fax and written correspondence, leveraging work queues to organize work efficiently. Work also includes reviewing insurance remittance advices, researching denial reasons and resolving issues through well-written appeals.
Essential Functions
- • Follows up on insurance and government payor claims to research and resolve unpaid claims and denials in follow-up work queues by contacting payers and/or patients for status. Identifies trends and assists lead/supervisor to provide team with insurance plan updates, reconsideration/appeal recommendations, and opportunities for improvement to aid in the quality and productivity requirements for their roles. • Responsible for obtaining reimbursement information when payment and remit are both provided via paper. • Communicates effectively over the phone and through written correspondence to explain why a balance is outstanding and denied using accurate and supported reasoning based on EOBs, medical records, and payer specific requirements. • Resubmits claims with necessary information and medical records when requested by payer through paper or electronic methods to ensure payments from third party payors. Monitors and reviews denial reason codes, plan limitations and works with other areas of revenue cycle when necessary to resolve issues. • Organizes open accounts by denial type or payer to quickly address in bulk with representatives over the phone, via spreadsheet, utilizing an on-line payer portal, etc. • Applies a thorough understanding/interpretation of Explanation of Benefits (EOBs) and remittance advices. • Accurately documents patient accounts of all actions taken in the system. • Responsible for resolving work queues according to the prescribed priority and/or per the direction of management and in accordance with department expectations. Assists in managing and resolving accounts from the workloads of other team members to prevent backlogs. Identifies high-risk accounts and prioritizes follow-up actions accordingly. • Assist with training of staff by contributing to the development of ongoing training and reference material to aid in the consistency of handling appeals and reconsideration of claims. Assists with identifying future development opportunities for team members. • Recognizes when additional assistance is needed to resolve insurance balances and escalates appropriately and timely through defined communication and escalation channels.
- Anticipates & identifies potential areas of concern or improvement within the follow-up functions. Proactively assists with or takes initiative on escalated issues as necessary or as directed by leadership
- Keeps current on payor requirements though workshops, newsletters, and websites.
- Complies with Federal and State billing requirements. Also complies with Health Information Portability and Accountability Act (HIPAA) and Electronic Data Interface (EDI) transaction formats.
Other duties as assigned by leader and organization.
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Education Qualifications
- High School Diploma or GED equivalent Required
- Associate's Degree from an accredited college or university in Information Systems, Business, Finance, or related field required. Preferred
Experience Qualifications
- Minimum 3 years of experience working with commercial and government billing and reimbursement processes. Required
Skills and Abilities
- Organized, self-motivated, and able to work independently of direct supervision to carry out responsibilities
- Intermediate computer skills including the use of spreadsheet programs and word processing programs.
- Knowledge of general concepts and practices that relate to hospital and professional billing, collection and reimbursement, the healthcare field, and specific policies, standards, procedures and practices that pertain to the assigned functions.
- Knowledge of medical insurance, CPT and ICD codes.
- Ability to demonstrate excellent interpersonal skills, demonstrating attention to detail and critical thinking skills within the context of the assigned functions, with a commitment to accuracy.
- Ability to troubleshoot, understand and/or adapt moderately complex oral and or written instructions/guidelines to diverse or dissimilar situations.
- Ability to perform non-complex arithmetic calculations
- Ability to understand and apply government/commercial insurance reimbursement terms, contractual and/or other adjustments and remittance advice details.
Ability to keep abreast of trends, developments and changing regulatory requirements that impact matters within designated scope of responsibility.
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Children’s is an equal opportunity employer, embracing and valuing the unique strengths and differences of people. We cultivate an inclusive environment of respect and trust where we all belong. We do not discriminate based on race, ethnicity, age, gender identity, religion, disability, veteran status, or any other protected characteristic.
