I have been working in insurance for 30 plus years. I am currently a Denial Resolution Specialist at UMass. I get lists every week of claims that have been denied by the insurance companies. We have to understand why it was denied. I try to get authorization for it or write an appeal or adjudicate for payment. What happens is someone comes to the hospital and they create a claim for the insurance company. Sometimes there is a problem and sometimes we need to get authorization. We need to do extensive research to understand what has gone wrong and how to change it.
I love the problem solving that my job requires. Developing relationships with different people from insurance companies has been really helpful in being able to get these claims through. We call the insurance companies and speak with them and hopefully get the claim reprocessed. We develop relationships with people from these companies and you get to know them well. I have developed these relationships and when there is a further problem we are able to go through it together. They are going to try harder to solve the issues and if there is a mistake on their end then they try to fix it as soon as possible and speed up the process instead of it coming back.
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Sometimes, we get to speak with the patients and ask them to call the insurance company to just confirm who the primary insurer is. When I get to talk to patients who might be older and not understand how their insurance works, it is reassuring and warming to let them know to call the insurance company and then I can work with the insurance company to really resolve their insurance issues. This impacts not only their current payment, but also future claims. That is what is really rewarding.
For example, we have talked to people who have been in a car accident. In these cases, we need the patient to call Medicare to update their status stating that either the claim is not due to the injuries from auth or Worker’s comp or that the auto coverage payment has been maxed out. You need to be able to talk to people effectively so that they will want to assist and make it into a positive.
Work for us has remained similar post-COVID. One of the things that has changed is that we can't scan in documents, but we can use our phones and use the equipment from our office. We are able to use the UMass phone system from our homes ensuring that the calls are secure. I am happy there is not a lot of background noise at home so I can focus more. It is quieter when I am making calls as well because the phone lines are not always great. Also, I don't have a commute anymore and that has been so helpful. I can add a few more hours to my day problem solving and working a job that I truly enjoy!