INSURANCE SPECIALIST in Brentwood, Tennessee at MedCycle Management

Position Summary
The Claims Tracking Representative is responsible for reviewing and resolving outstanding insurance claims by utilizing payer websites, phone calls, and internal claim management tools. This role works closely with insurance carriers to determine claim status, resolve billing issues, verify patient eligibility, update Coordination of Benefits (COB) information, and ensure claims are billed to the appropriate insurance payer for timely reimbursement.

Essential Duties and Responsibilities

• Review and prioritize claims assigned through SPAI AI Claims Management Tool.
• Research and resolve claims identified as “No Claim on File” (NCOF), “Status Unknown,” or other unresolved claim statuses.
• Contact insurance payers by phone to obtain claim status, denial details, payment information, and claim resolution requirements.
• Utilize payer portals to investigate claim status, payment history, eligibility, and authorization information.
• Verify patient insurance coverage and eligibility for dates of service.
• Identify and update Coordination of Benefits (COB) information to ensure claims are submitted to the correct primary, secondary, or tertiary payer.
• Correct insurance information and rebill claims to the appropriate payer when necessary.
• Document all account activity, claim status updates, and payer communications accurately within company systems.
• Follow up on unresolved claims according to established timelines and productivity standards.
• Escalate complex claim issues to management or appropriate departments as needed.
• Maintain knowledge of payer guidelines, insurance regulations, and billing requirements.
• Meet departmental quality, productivity, and collection goals.
• Perform other duties and responsibilities as assigned by management to support departmental and organizational needs.

Qualifications

• High school diploma or equivalent required; associate degree preferred.
• Minimum 1-2 years of medical billing, revenue cycle management, or healthcare claims experience preferred.
• Knowledge of commercial insurance, Medicare, Medicaid, and managed care plans.
• Experience using payer portals and claim status systems.
• Understanding of Coordination of Benefits (COB), eligibility verification, and insurance claim processing.
• Strong phone communication and problem-solving skills.
• Ability to multitask and manage a high volume of accounts.
• Proficiency with EMR, billing systems, and Microsoft Office applications.
• Strong attention to detail and organizational skills.

Key Performance Indicators (KPIs)

• Daily, weekly and monthly production goals assigned by management.
• Reduction of NCOF and Status Unknown accounts.
• Accuracy of claim and system documentation.
• Timely follow-up on outstanding claims.
• Rebilling accuracy.
• Productivity and quality metrics established by management.

Reports To: Revenue Cycle Operations Manager
Department: Revenue Cycle Management / Insurance Follow-Up