Claims Reimbursement Rep (BHS)

MISSION, VALUES and SERVICE GOALS

MISSION: We deliver outstanding care, inspire health, and connect with heart.

VALUES: Trust. Respect. Integrity. Compassion.

SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.

Documentation/Follow-up

• Obtains and reviews Denials and Appeals reports, identifying accounts that meet criteria for follow up.
• Collaborates with all members of the Revenue cycle and clinical team to reduce third-party payer denials.
• Coordinates denial management process, focusing upon retrospective follow-up and appeal processing to appropriately maximize reimbursement based upon services delivered and ensure that the claim is paid/settled in the most timely manner possible.
• Appeals denied claims including writing and submitting appeals.
• Performs account follow-up with insurance companies to determine if the correct reimbursement has been received.
• Contact governmental and commercial payors to pursue collection efforts of favorable appealed claims.

Reports

• Maintains records, reports and files as required by established policies and procedures.
• Coordinates communication and follow up processes related to denials and appeals, ensuring that activities are tracked, trended, and reported to key stakeholders.
• Identifies solutions to issues affecting reimbursement as it relates to denial prevention (prospective and concurrent).
• Maintains statistics related to appeal follow up and collection activities (for example, relative to established goals and budgets) and communicates with the Manager.
• Attends internal BHS meetings in order to occasionally serve as a technical resource to the Denials and Appeals Department.

Problem Prevention and Solutions

• Act as a professional resource in regards to optimization of key revenue management, denials prevention, and billing compliance.
• Identify Root-Cause analysis as it relates to denials, appeals, and follow up activities.
• Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by:
• Providing excellent customer service at all times.
• Completing other job-related duties and projects as assigned.
• Attending in-services and department meetings; also participating in continuing education.
• Reading current professional literature and journals.
• Attending billing/coding seminars when approved.

Organizational Responsibilities

• Attends and participates in department meetings and is accountable for all information shared.
• Completes mandatory education, annual competencies and department specific education within established timeframes.
• Completes annual employee health requirements within established timeframes.
• Maintains license/certification, registration in good standing throughout fiscal year.
• Patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
• Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
• Adheres to regulatory agency requirements, survey process and compliance.
• Complies with established organization and department policies.
• Available to work overtime in addition to working additional or other shifts and schedules when required.

Education and Experience

• The knowledge, skills and abilities as indicated below are normally acquired through the successful completion of a high school diploma or equivalent.
• Bachelor's Degree in related field preferred.
• A minimum of three years of experience in a medical/billing environment and previous collection experience is required.
• Knowledge of insurance and governmental programs, regulations, and billing processes, managed care contracts, and coordination of benefits is required.
• Working knowledge of medical terminology and medical record coding experience required.