Billing/Claims Specialist

Finance & Accounting
in Ormond Beach
, FL
Reference: 19-03885


The Billing/Claims Specialist will be responsible for follow up on Third Party Claim Reimbursements for the identification, billing and collection of payments.  Under the direction of the Manager, this position will be responsible for handling all functions relative to these areas and providing support and service to all facilities.


  • Responsible for performing and processing accurate billing procedures for all payors, electronically through SSI (a medical claims management system that assists the insurance reimbursement team with claims editing and validation)
  • Work independently, meeting time and daily deadlines in an accurate and efficient manner, communicating any issues to leadership
  • Ensure expeditious and accurate insurance reimbursement for all government and managed care payors
  • Update a high volume of daily claims appropriately in SSI system
  • Appropriately determine, initiate, and follow through on the status of claims in SSI, such as place on hold, delete, or assign account error to responsible, supporting department
  • Document billing, follow-up and/or collection step(s) that are taken as well as the result and next step needed to resolve the assigned payment
  • Monitor and audit status of errors assigned to other areas or PFS teams for all payors daily, ensuring timely follow up and expeditious billing
  • Communicate with key management staff and supporting department partners effectively and professionally to ensure key metrics are being addressed timely
  • Assist in identifying key trends as applicable or opportunities for improvement
  • Maintain communication between external or contracted agencies, business vendors and partners (i.e. Revenue Management, Laboratory, Contract Management, Case Management, Payors, etc.) ensuring compliance between external relationships, knowledge of contractual terms, and performance protocols and inform leadership of any foreseeable issues with partners
  • Assist Customer Service with patient concerns/questions to ensure prompt and accurate resolution is achieved
  • Process and record agency audit notifications and respond in designated timeframe to ensure compliance with government and/or contractual requirements for timely response
  • Work all assigned insurance payors to ensure proper reimbursement on patient accounts to expedite resolution
  • Process medical, administrative, technical appeals, request refunds when applicable, and rejections of insurance claims
  • Ensure proper escalation is met when account receivable is not collected in a timely manner
  • Analyze daily correspondence (denials, underpayments) to appropriately resolve issues
  • Respond to written correspondence received from payor and/or patients
  • Responsible to stay current on all active, assigned accounts which prevents abandonment, uncollected account receivables
  • Assist Customer Service area with patient concerns/questions to ensure prompt and accurate resolution is achieved
  • Ensure we foster a team-spirited approach while interacting with co-workers, peers, management, etc.
  • Stay committed to delivering superior customer service to our patients
  • Analyze previous account documentation to determine appropriate action(s) necessary to resolve each assigned account
  • Initiate next billing, follow-up and/or collection step(s), not limited to calling patients, insurers or employers, as appropriate
  • Remit initial or secondary bills to insurance companies immediately following payment from the primary insurance payor
  • Coordinate with multiple departments to resolve denials and payment discrepancies including but not limited to Case Management, Billing, Coding, and Refunds departments
  • Key members of the team will also be responsible for specific, daily functions including monitoring for and processing 24 and 72 hour overlapping accounts and monitoring and processing status changes.
  • Apply appropriate adjustments to accounts because of the audit
  • Analyze previous account documentation to determine the appropriate write off code of medically denied charges for the right reason
  • Review follow-up codes submitted to other departments daily for appealed claims and communicate with departments to ensure timely response
  • Perform comprehensive and accurate follow-up on each account to ensure prompt resolution is achieved in a timely manner
  • Document steps taken as well as the result and next step needed to resolve the assigned payment
  • Maintain accurate and comprehensive records of each phase of appeal
  • Work appeal denials daily to ensure accounts are processed to next appeal level in a timely manner or determination is made for acceptance of denial
  • Facilitate appeals on assigned accounts when appropriate and as specified in payor contract to receive payment for denied services
  • Monitor accounts for incorrect insurance address/information and follows up on accounts that have been billed to payors to review for timely payment or denial
  • Re-class daily and resubmit corrected claim as appropriate
  • Review incoming correspondence and customer service requests within 24 hours of receipt to appropriately resolve issues and promote positive relationships with patients and payors
  • Complete account follow up daily, maintaining established goal (s), and notify Lead Rep, when necessary, of issues preventing achievement of such goal(s)
  • Document the billing, follow-up and/or collection step(s) and all measures taken to resolve assigned accounts, including escalation to Manager if necessary
  • Other duties as assigned


  • Computer/data entry skills
  • Proficiency in performance of basic math functions
  • Communicate professionally and effectively, both verbally and in writing


  • High School diploma or GED required
  • One year of experience in healthcare, finance, accounting, banking, insurance, or related fields
  • One year of college can be substituted for experience
  • One year of experience in healthcare claims processing or collections


  • Exhibit ICARE values and loving care in all interpersonal contacts
  • Establish and maintain courteous, tactful and professional level of interpersonal skills necessary to deal effectively with customers and populations served, including patients, guests, co-workers, the public, medical staff and external business associates
  • Demonstrate effective oral and written communication skills; maintain required level of confidentiality; interact effectively with employees at all levels
  • Conform to all  policies and procedures including but not limited to the mission/vision/values and philosophy, Customer Service pledge, corporate compliance, Rules of Conduct as outlined in the “Guidelines for Employees” handbook, no smoking and dress code
  • Establish and maintain a history of regular attendance; make appropriate use of PDO, and observe department call-in procedures for absence; establish and maintain punctual work habits
  • Exhibit timely arrival and departure and dependable time habits including meals and other breaks
  • Attend/participate in mandatory facility-wide and department training/meetings as required including but not limited to department huddles, annual education, safety training, town halls,  etc.
  • Demonstrate and apply knowledge of fire, safety, security, disaster procedure regulations and National Patient Safety Goals as presented in orientation, outlined in safety manual, and as pertains to each work area
  • Support departmental and organizational mission by embracing and demonstrating a commitment to sacred work, appropriate use of resources providing assistance to team members, accepting work or schedule assignments, participating in process and performance improvement as required
  • Required to respond to emergency situations (i.e., disasters, hurricanes, etc.) by reporting to department and staying until the crisis is over or position is covered by incoming personnel.  This is a mandatory requirement.  Refusal to respond may result in termination.