Insurance Claims Specialist (Must Reside in IL, WI or IA).

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Position Purpose:  The High Impact Claims Specialist will serve as a primary resource to identify high dollar collection issues, increase revenue, and track and trend payor collection issues.  As a seasoned Claims Specialist, you will serve as the go-to expert for resolving complex collection challenges with our commercial payors. In this critical role, you'll collaborate closely with management to support the A/R team's initiatives, enhance revenue generation, and monitor and analyze payor collection trends. The ideal candidate will quickly adapt to our systems and make an immediate impact.   

Qualifications/Basic Job Requirements:  

• High School diploma or GED required, or bachelor’s degree preferred.
• Extensive experience in a healthcare environment with knowledge of claims processing, denial management, and healthcare collections.
• Experience in researching and solving high dollar complex insurance claims and denials.
• Knowledge of and experience working with ERISA laws.
• Adequate written skills to accurately complete required documentation within the time frames prescribed.
• Excellent organizational and customer service skills.
• Excellent oral and written communication skills required.
• Ability to accurately complete required documentation within the times prescribed.
• Ability to work independently, manage time effectively and able to prioritize tasks.
• Proficient in the use of Microsoft Word, Excel, and PowerPoint. Advanced Excel skills including the ability to produce graphs, charts, and tables, use spreadsheets efficiently and perform calculations and automation to process large volumes of data.
• Ability to analyze and trend data.

Essential Responsibilities:  

1. Review and process all BC/BS and Commercial high dollar claims (over $10,000) for denials, payor issues and payment trends.
2. Submit, process and track all appeals for BC/BS and commercial payors.  Maintain knowledge of ERISA laws governing employee benefit plans and manage the appeal process for these claims.
3. Assist A/R staff with complex claim issues they are unable to resolve in a timely manner.
4. Track and trend all Single Case Agreements. Work closely with Contracting on any SCA payment issues / concerns.
5. Review payments for BC/BS and commercial payors for rate validation according to our contracts.
6. Track all denial outcomes for payment, write-offs and transfers to client liability. Identify the root cause for the adjustments to client accounts. Work with management to review adjustment trends and identify potential solutions.
7. Help maintain integrity of accounts receivable ledger, including aged receivable monitoring on an ongoing basis.
8. Responsible for maintaining current knowledge of revenue components including benefit plans, contract terms and rates and billing forms and codes.
9. Check status of claims through use of telephone, websites and/or other means available.
10. Document adjustments needed to patient accounts.
11. As needed, participate in phone conference calls with payors.
12. Pursue collection activities and follow up for balances outside of established norms.
13. Coordinate collection activities with outside agencies, including court appearances, as needed.
14. Provide feedback & education management with regards to issues that impact revenue flow.
15. Provide appropriate documentation and reports designed to assist in fiscal management of the agency.
16. Serve as a member of the SWAT Team and participate in team meetings.
17. Serve as a member of the Revenue Cycle Team and participate in all team meetings and activities.
18. Understand and comply with all of the principles established by the Rosecrance Corporate Compliance Program and Code of Ethics.
19. Perform all responsibilities in compliance with the mission, vision, values and expectations of Rosecrance.
20. Deliver exceptional customer service consistently to every customer.
21. Serve as a role model for other staff, clients and customers and demonstrate positive guest relations in representing Rosecrance.
22. Assume other related responsibilities as assigned by management.

Schedule: 8-hour shifts 

• Shift: 8:30am - 5:00pm
• Monday - Friday

Work Location: Rosecrance Health Network - Rockford, IL (must be located in the states we operate: Illinois, Iowa, or Wisconsin)

• Can be remote!

Benefits: Rosecrance val