Claim Specialist (CBO) - Full Time

Title: Claim Specialist Department: Central Business Office

FLSA Status: Non-Exempt Reports to: CBO Supervisor

Job Number: Approved/Revised Date:

About Wilmington Health

Since 1971, Wilmington Health has been committed to the care and health of our community in Wilmington as well as all of Southeastern North Carolina. Wilmington Health is structured as a multi-specialty medical practice with primary care providers integrated into the system. In this way, Wilmington Health is able to provide a comprehensive and coordinated approach to the care of all our patients. Wilmington Health is committed to using collaborative, evidence-based medicine in providing the highest quality of care to the patients we serve.

Purpose:

Ensures claims are received by the correct payer in an accurate and timely manner.

Essential Duties/Responsibilities:

Research and resolve claim edits generated in billing system and clearinghouse, as assigned

Research and resolve first-level denials, as assigned

Verify Medicaid eligibility for hospital-based services provided to uninsured patients

Research and confirm contracted status of minor insurance plans, document findings as a resource for others; follow established protocol to notify the patient of findings, explain financial responsibility for future appointments; work with System Build Team to activate or deactivate plans as needed

Update insurance information on patient account as appropriate; take action on previous dates of service as needed

Correspond to carrier for such things as appeals and or inquiries, within carrier timely filing guidelines and following carrier’s published protocols

Communicate all insurance regulation changes to supervisor, providers and other departments as appropriate

Contact carrier and or patient to follow-up on denials and termination of coverage

Respond to telephone calls, review and respond to correspondence in a timely manner

Work with Coder Team regarding appropriate code changes for effective appeals

Communicate trends to supervisor to assist in pro-active training and protocols

Other Duties:

As assigned by manager

Qualifications:

Required:

High school diploma or general education degree (GED)

3-5 years' experience in a medical office environment or equivalent combination of education and experience

Full COVID 19 vaccination is required as a condition of employment for all positions with Wilmington Health. Documentation is required prior to orientation.

Wilmington Health is an Equal Opportunity Employer committed to providing equal opportunities to all applicants and employees. We are committed to treating everyone equally and with respect regardless of race, age, sex, religion, national origin, citizenship, marital status, veteran’s status, sexual preference, disability, genetic information, or any other class protected under state or federal law.

ADA Physical Demands:

Rarely (Less than .5 hrs/day) Occasionally (0.6 – 2.5 hrs/day) Frequently (2.6 – 5.5 hrs/day) Continuously (5.6 – 8.0 hrs/day)

Claim Specialist Competencies

General

• Customer Service
• Professionalism/Integrity/Responsibility
• Teamwork/Process Focus
• Dependability/Punctuality
• Interpersonal Relationships/Communication
• Judgment/Decision Making/Problem Solving
• Quality/Quantity
• Initiative
• Safety/Housekeeping
• Organizational Skills/Time Management

Department Specific:

• Decision-making skills regarding ‘next step’ when working edits, rejections and denials
• Resourceful in finding appropriate information to assist in resolving the issue at hand
• Up-to-date with carrier changes as well as specialty-specific changes
• Effectively communicate changes to departments and co-workers
• Use all available tools and resources to accomplish job duties in an efficient and timely manner
• Strong computer skills, i.e., Windows environment, word processing, spreadsheets, etc.
• Effective use of software and web-based carrier sites for submission of claim and requested documentation
• Reliable source of information in regards to assigned carrier rules and requirements

• 
  2-3 years of experience in medical billing, specifically with claims edits, eligibility, level 1 claims denials.