Insurance Verification and Billing Specialist - Elma

About Us:

The Insurance Verification and Billing Specialist is responsible for managing all aspects of insurance verification, claims processing, billing, and reimbursement for an Article 16 Clinic. This role ensures accurate and timely revenue cycle operations while maintaining compliance with New York State regulations, Medicaid guidelines, and payer requirements specific to OPWDD-funded services. The Clinic Insurance and Billing Verification Specialist receives supervision from Article 16 Office Manager or Designee. 1. Foster a team culture of belonging by promoting inclusiveness and ensuring all individuals feel heard and respected across all projects and interactions. 2. Uphold integrity by maintaining transparency in decision-making, delivering on commitments, and holding oneself and others accountable. 3. Demonstrate a commitment to personal and professional growth by actively pursuing development opportunities, embracing new challenges, and continuously improving performance. 4. Verify patient insurance eligibility, coverage, and benefits prior to service delivery (10%) 5. Obtain and track prior authorizations as required (10%) 6. Maintain accurate payer and patient insurance information in the electronic health record (EHR) system (5%) 7. Prepare, review, and submit claims to Medicaid, Medicare, and commercial insurers (10%) 8. Ensure claims are coded accurately using appropriate CPT, ICD-10, and HCPCS codes (10%) 9. Monitor claim status and resolve rejections, denials, and discrepancies in a timely manner (5%) 10. Track and follow up on outstanding claims and unpaid balances (5%) 11. Investigate and resolve billing issues, including underpayments and denials (10%) 12. Coordinate with payers to ensure proper reimbursement (5%) 13. Ensure billing practices comply with Article 16 regulations, OPWDD standards, and payer guidelines (2%) 14. Maintain detailed and accurate documentation for audit readiness (2%) 15. Stay current on regulatory changes impacting billing and reimbursement (2%) 16. Work closely with clinical staff, administrative teams, and leadership to resolve billing issues (2%) 17. Provide guidance to staff on documentation requirements to support billing (2%) 18. Communicate with patients and families regarding billing inquiries when necessary (2%) 19. Coordinate annual reviews and contracts for Medicare Part D coverage for residential programs. (5%) 20. Respond to Release of Information (ROI) requests in accordance with departmental policies. (2%) 21. Communicate regularly with Treatment Coordinators regarding authorization statuses. (2%) 22. Provide general support to clinic staff as needed. (2%) 23. Assist Clinic Office Manager with scheduling and confirming appointments as needed. (1%) 24. Assist Clinic Office Manager with Precision Care report execution and treatment plan distribution. (1%) Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice. The Clinic Insurance and Billing Specialist must have a High School Diploma or

G.E.D. PLUS

two (2) years medical office or related experience. Knowledge of medical insurance billing preferred OR Associate Degree in related field can be substituted for experience. Knowledge of computers and relevant software application; copy machine; scanners, etc. 1. Excellent written and verbal communication skills. 2. Excellent interpersonal and customer service skills. 3. Excellent organizational skills and attention to detail. 4. Excellent time management skills with a proven ability to meet deadlines. 5. Ability to function well in a high-paced and at times stressful environment. 6. Strong analytical and problem-solving skills. 7. Ability to adapt to the needs of the organization and employees. 8. Ability to prioritize tasks and to delegate them when appropriate. 9. Strong computer skills using Microsoft Office products, Internet, email, and HRIS system. 10. Reasoning ability to interpret agency policies. Must maintain regular work schedule of 35 hours per week as well as perform essential duties as described on attached for Valid NYS Driver's License is required, as travel between sites, to meetings, etc., during the workday may be required You are required to maintain your certifications and annual training, as applicable to your role. sasi is an equal opportunity employer. We are committed to creating an inclusive environment for all employees and applicants. We do not discriminate based on race, color, religion, gender, gender identity, sexual orientation, national origin, disability, or any other characteristic protected by law.