Sr Insurance Specialist - Commercial/Blue Cross in Holyoke, Massachusetts at Holyoke Medical Center

Disclaimer for Job Postings

Note: The compensation range noted above represents the base salaries for all positions at a given grade across the health system. Typically, a new hire can expect a starting salary somewhere in the lower part of the range. Actual salaries will be determined based on the candidate's relevant experience. No employee will be paid below the minimum of the range.

Holyoke Medical Center is looking for a Sr Insurance Specialist. This position manages complex medical claims, acting as a subject matter expert to investigate, adjudicate negotiate settlements, ensure compliance and mentor junior staff, focusing on accurate and timely and cost-effective claims resolution while maintaining strong communication with providers, payers and internal teams. Works all claims as assigned/directed.

DUTIES AND RESPONSIBILITIES:

Serve as subject matter expert, providing guidance on policy, regulations and complex claims scenarios.
Conduct in-depth analysis, research discrepancies, prevent fraud and develop plans for claims resolution.
Handles escalated inquires, build relationships with providers/payers and communicate claims status.
Assist in training, coaching and provide senior support to less experienced team members.
Review and process complex hospital claims and determine coverage based on policy, medical necessity and contracts.
Able to work all aspects of Commercial Managed Care, Medicare Advantage, and Medicaid Advantage Care accounts sliding between Financial Classes as needed for Billing, Follow-up, Denials Management, Credit Balance and Account resolution.

Required Skills
Must show honesty, integrity, strong ethics, data entry skills and time management skills
Insurance follow up experience especially Blue Cross and all Commercial Lines
Strong understanding of Medetech and finThrive billing programs
Strong Verbal and written skills for preparing and presenting appeals, negotiating settlements and presenting reports to Senior Management.
Proactive approach to resolving discrepancies between insurance policy terms and provider charges
Ability to analyze complex data, identify issues and solve problems
Proven background in handling complex institutional or healthcare related claims
Proficiency with claims software and MS Office (especially Excel).
Strong time management, organization skills and ability to work independently or in a team
Good plus knowledge of ICS/HCPCS/CPT Coding and medical terminology
Knowledge of commercial, state and federal healthcare regulations
Excellent Math Skills and knowledge of general accounting principals
Ability to logically and accurately organize data
Excellent problem solving skills
Strong attention to detail

QUALIFICATIONS/JOB REQUISITES:

Education: High School Diploma or GED is required, an Associate or Bachelor’s degree in Health Administration or related Study preferred

Experience: Eight plus (8+) years in the health insurance, hospital business office or claims processing/management.