Insurance Specialist IIBuild a rewarding career at the intersection of healthcare, customer service, and problem-solving. As an Insurance Specialist II, you'll gain valuable industry knowledge while helping patients and care teams navigate the complexities of insurance and healthcare coverage. Why Choose Guthrie: Voluntary 403(b) Retirement Plan with Fidelity investment options Employee Assistance Program providing confidential support for personal and professional well-beingPTO starts Day 1Friendly, inclusive work family where you'll feel valued and supported Recognized as a Top Healthcare Employer: Best Places to Work 2025 Modern Healthcare America's Greatest Workplaces in Healthcare 2025, 2026 Newsweek America's Best-In-State Employers (PA) 2025 ForbesAmerica's Best Employers for Healthcare Professionals 2025 ForbesAmerica's Best Employers for Women 2025 Forbes Schedule & Coverage: Full-Time, Day Shift
Position Summary:
Fulfills all requirements of the Insurance Specialist I role while serving as a group leader by participating in staffing and employment-related activities. Serves as a departmental resource specialist and provides training to Insurance Billing Specialists I and related support staff. Works closely with the Director, Manager, Supervisor, and Application Analyst on daily priorities to maintain a high level of integrity within the unit. Takes the necessary action to complete complex insurance billings and appeals. Reviews and analyzes insurance processing procedures to identify potential problem areas and recommends process improvements. Prepares reports as required and requested, collaborates with insurance payers on problem claims and processes, and resolves outstanding accounts receivable and credit balances as assigned.
Education:
High school diploma or equivalent required.
CPC, CCA, RHIA, or RHIT certification in medical billing and coding preferred.
Associate degree preferred.
Experience:
Minimum of three years of insurance billing experience or CPC certification required. Must demonstrate current competencies applicable to the position and have proven experience performing required tasks independently while contributing to a team environment. Must maintain knowledge of medical terminology, CPT coding, ICD-10 coding, and insurance regulations. Strong organizational and customer service skills are essential. Previous experience working in a high-volume, fast-paced environment is required, along with demonstrated self-motivation to develop and maintain the knowledge and skills necessary for success in the role.
Essential Functions:- Identifies and evaluates denials for assigned payers and/or specialties to determine specific issues and patterns that need to be addressed. Serves on Denial Task Forces and assists in developing action plans to reduce denials and streamline clean claim submissions.
- Exports data, prepares spreadsheets, and creates and runs reports used in resolving outstanding claims, including trending reports, special projects, and worklists. Identifies trends and provides follow-up for claims requiring correction or appeal.
- Demonstrates proficiency in analyzing complex billing problems, preparing appeals, challenging payer policies, and pursuing appeal turnover when necessary.
- Works with the team and department management to develop and train staff on internal rejection protocols. Maintains current knowledge of coding requirements, reimbursement policies, payer guidelines, and industry best practices.
- Ensures staff adherence to protocols through auditing and education.
- Identifies and promptly reports payer, system, or billing issues. Works with the Applications Analyst, Supervisor, Manager, and Director to provide recommendations and support resolution efforts.
- Works with the team and payers to ensure timely resolution of assigned credit balances. Assists with preparation of annual escheatment documentation.
- Leads payer-specific external claim audit activities in collaboration with Management, Compliance, Medical Records, and Clinical Operations.
- Serves as a group leader by performing one or more of the following duties:
- Employee training
- Routing work assignments
- Participation in employment-related issues
- Reviews requested adjustments from Specialists and approves low-dollar adjustments within policy guidelines. Collects information and supporting documentation for Director approval of high-dollar adjustments.
- Performs testing and monitoring of new system logic and processes with the Business Analyst and/or Manager.
Other Duties:- Answers phone calls and correspondence, providing requested information to assist in resolving account balances.
- Maintains knowledge of and performs duties in compliance with Guthrie Medical Group and payer guidelines.
- Provides feedback related to workflow processes to promote efficiency.
- Utilizes Epic system functions accurately to perform assigned tasks, including:
- Charge corrections
- Invoice inquiries
- CreditsCharge review
- Claim edits277 rejections
- Related billing functions
- Trains staff on these functions as needed.
- Demonstrates excellent customer service skills for both internal and external customers while promoting the same within the team environment.
- Maintains strict confidentiality of patient health information in accordance with HIPAA regulations.
- Assists with and completes special projects and other duties as assigned.
- Joining the Guthrie team allows you to become a part of a tradition of excellence in health care. In all areas and at all levels of Guthrie, you'll find staff members who have committed themselves to serving the community.
The Guthrie Clinic is an Equal Opportunity Employer.
The Guthrie Clinic is a non-profit, integrated, practicing physician-led organization in the Twin Tiers of New York and Pennsylvania. Our multi-specialty group practice of more than 500 physicians and 302 advanced practice providers offers 47 specialties through a regional office network providing primary and specialty care in 22 communities. Guthrie Medical Education Programs include General Surgery, Internal Medicine, Emergency Medicine, Family Medicine, Anesthesiology and Orthopedic Surgery Residency, as well as Cardiovascular, Gastroenterology and Pulmonary Critical Care Fellowship programs. Guthrie is also a clinical campus for the Geisinger Commonwealth School of Medicine.
