Insurance Specialist

Core Responsibilities :

• Research payer denials related to referral, pre-authorization, notifications, medical necessity, non-covered services, and billing resulting in denials and delays in payment.
• Independently write professional appeal letters.
• Submit detailed, customized appeals to payers based on review of medical records and in accordance with Medicare, Medicaid, and third-party guidelines as well as WCR policies and procedures.
• Submit retro-authorizations in accordance with payor requirements in response to authorization denials.
• Identify denial patterns and escalate to management as appropriate with sufficient information for additional follow-up, and / or root cause resolution.
• Make recommendations for additions / revisions / deletions to claim edits to improve efficiency and reduce denials.
• Identify opportunities for process improvement and actively participate in process improvement initiatives.

Customer Service Standards :