Medical Claims Specialist - Columbia Orthopaedic Group

Job Title: Insurance Follow Up Specialist

Location: Columbia Orthopaedic Group

Job Summary:

The Claims Specialist is responsible for managing the entire lifecycle of insurance claims, from submission to resolution, within an orthopedic practice. This role involves verifying patient insurance information, preparing and submitting claims, following up on unpaid or denied claims, and working closely with insurance companies and patients to ensure timely and accurate reimbursement for services provided.

Key Responsibilities:

Claims Management:

   - Review and verify patient insurance information and medical documentation to ensure accuracy and completeness.

   - Prepare, submit, and track insurance claims using appropriate billing software and platforms.

   - Ensure claims are filed in accordance with payer guidelines and coding standards.

Follow-Up and Resolution:

   - Monitor and follow up on outstanding claims and denials to resolve issues and expedite payment.

   - Investigate and address claim denials or rejections by reviewing claim history, communicating with insurance carriers, and making necessary corrections or adjustments.

   - Work with the billing department and healthcare providers to obtain additional information or documentation required for claim processing.

Compliance and Documentation:

   - Maintain up-to-date knowledge of insurance policies, billing regulations, and compliance requirements specific to orthopedic practices.

   - Ensure all claims are processed in compliance with federal, state, and payer-specific regulations and guidelines.

   - Document all claim-related activities and communications thoroughly and accurately.

Patient Interaction:

   - Communicate with patients regarding their insurance coverage, claim status, and any outstanding balances.

   - Address patient inquiries and concerns related to billing and insurance claims.

Reporting and Analysis:

   - Generate and analyze reports related to claim status, denials, and reimbursement trends to identify and address potential issues.

   - Provide feedback and recommendations to improve billing and claims processing efficiency.

Qualifications:

Education: High school diploma or equivalent required; Associate's or Bachelor's degree in Healthcare Administration, Business, or a related field preferred.

Experience: Proven experience in medical billing and coding, preferably in an orthopedic or healthcare setting.

Skills:

  - Proficiency in medical billing software and electronic health record (EHR) systems.

  - Strong understanding of insurance processes, coding, and regulations (CPT, ICD-10, HCPCS).

  - Excellent communication and problem-solving skills.

  - Ability to manage multiple tasks and prioritize effectively.

Certifications (Preferred):

- Certified Professional Coder (CPC) or Certified Coding Specialist (CCS). 

- Certification in medical billing and coding (e.g., AAPC, AHIMA).

-  Pay Differential: Employees who hold a relevant certification (CPC, CCS, etc.) will receive a pay differential of $2.00 above the base hourly rate.  

Working Conditions:

Environment: Office setting within the orthopedic practice.

Hours: Full-time position, typically Monday to Friday with standard office hours.

Additional Information:

The Claims Specialist will work closely with the billing team, healthcare providers, and insurance representatives to ensure the practice’s revenue cycle operates smoothly. This role requires attention to detail, strong organizational skills, and the ability to handle sensitive information with confidentiality.  Hybrid Work Opportunity: After successfully completing six months of employment and meeting performance expectations, there is potential for a hybrid work arrangement, combining remote work with in-office responsibilities.