GIRMC Insurance Claim Specialist

GENERAL SUMMARY:

Ensures accurate and timely reimbursement by reviewing, processing, and resolving medical claims in accordance with payer requirements and billing guidelines. Identifies and corrects claim issues, performs follow-up on unpaid or denied accounts, and documents actions to support resolution. Communicates with payers and internal teams to clarify requirements, address discrepancies, and facilitate account resolution. Applies revenue cycle knowledge and problem-solving skills to improve claim accuracy and support overall financial performance.

PRINCIPAL JOB FUNCTIONS:

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   *Commits to the mission, vision, beliefs and consistently demonstrates our core values.

   
   

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   *Reviews claims to ensure accurate and complete patient, insurance, and billing information prior to submission.

   
   

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   *Identifies and resolves claim edits, rejections, and denials using established payer guidelines and internal processes.

   
   

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   *Submits claims and performs follow-up on outstanding accounts through payer portals, phone, or other communication methods.

   
   

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   *Analyzes Explanation of Benefits (EOBs), remittance advice, and account activity to determine appropriate actions, including corrections, rebills, or appeals.

   
   

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   *Investigates account discrepancies and collaborates with internal teams to resolve coding, billing, or system issues.

   
   

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   *Communicates with payers, patients, and other stakeholders to obtain necessary information and facilitate account resolution.

   
   

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   *Documents all account activity, communications, and status updates clearly and accurately within billing systems.

   
   

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   *Assists with credit balance review and resolution, including adjustments, recoupments, or refunds as appropriate.

   
   

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   *Monitors assigned work queues and accounts to meet productivity, quality, and timeliness expectations.

   
   

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   Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.

   
   

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   Participates in meetings, committees and department projects as assigned.

   
   

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   Performs other related projects and duties as assigned.

   
   

EDUCATION AND EXPERIENCE:

High school diploma or equivalent required. One (1) year of healthcare revenue cycle, medical billing, or accounts receivable experience required. Must be at least 19 years of age to witness legal consents.