Insurance Specialist

Department: Consumer Division
Direct Report: Missy Conley, Director Consumer Division
Sec. Report(s): Jeanne Woodward, Vice President Consumer Division
Location: Roanoke, VA.

POSITION SUMMARY

The Insurance Specialist is responsible in analyzing the explanation of benefit (EOB) and/or client claim submission sheet to determine reimbursement formula. The Insurance Specialist calculates the reimbursement formula, if applicable, for claims submitted including facility and professional claims. The Insurance Specialist completes the reimbursement documentation into the system for consideration throughout the review process.

DUTIES AND RESPONSIBILITIES

Specific duties include:

  •  Evaluate Reimbursement Documents
    • Review Claim Cover Sheet for type of reimbursement
    • Review Explanation of Benefit (EOB)
    • Review Plan Documents for correct benefits
    • Review and understand policy provisions and exclusions
    • Other claim process issues as needed
  • Calculate Reimbursement 
    • Establish formula applied to received claims
    • Establish formula applied to pilot test claims
    • Complete Reimbursement Document in system
    • Other claim process issues as needed
  • Insurance Appeals Process
    • Review Appeal process in plan documents
    • Analyze to determine if appeal needs to be completed
    • Works with the Appeals representative to communicate appeal level
    • Other claim process issues as needed

 MINIMAL STANDARD REQUIREMENTS, SKILLS, AND ABILITIES

  • Must be computer savvy
  • Two years of experience in insurance claims processing
  • Two years’ experience working in excel and access programs
  • Fast typing skills with accuracy
  • Great attention to details
  • Ability to follow procedures

INTENT AND FUNCTION OF JOB DESCRIPTIONS

Job descriptions assist organizations in ensuring that the hiring process is fairly administered and that qualified employees are selected. They are also essential to an effective appraisal system and related promotion, transfer, layoff, and termination decisions. Well-constructed job descriptions are an integral part of any effective compensation system.

All descriptions have been reviewed to ensure that only essential functions and basic duties have been included. Peripheral tasks, only incidentally related to each position, have been excluded. Requirements, skills, and abilities included have been determined to be the minimal standards required to successfully perform the positions. In no instance, however, should the duties, responsibilities, and requirements delineated be interpreted as all-inclusive. Management reserves the right to modify, add or remove essential functions as business needs warrant. Additional functions and requirements may be assigned by supervisors as deemed appropriate.

In accordance with the Americans with Disabilities Act, it is possible that requirements may be modified to reasonably accommodate disabled individuals. However, no accommodations will be made which may pose serious health or safety risks to the employee or others or which impose undue hardships on the organization.