Revenue Cycle Insurance Spec | Business Group Admin | PRN Pool | Days

About the role

Responsible for obtaining appropriate reimbursement for Accounts Receivables for professional services of patients seen in physician offices, out-patient hospital, in-patient hospital, ASC, urgent care, ER, off-site hospitals, and Telehealth locations while maintaining timely claims submissions. Registers patients and completes necessary documentation including insurance verification and benefits determination. Researches charges to submit to appropriate carrier according to Federal/Managed Care rules, regulations, and compliance guidelines. Reviews codes using CPT, ICD-10, HCPCS, and CCI guidelines to ensure compliance with institutional compliance policies for coding and claim submission. Enters and bills professional charges into an automated billing system program. Utilizes resources and tools in the resolution of invoices following company policy for assigned payor/s. Resolves outstanding balances with internal and external communication with customers.

Responsibilities

• Triage invoices and determine appropriate action to obtain reimbursement for all types of professional services by physicians and non-physician providers, maintaining timely claims submissions and Appeals processes as defined by individual payors.
• Resubmit insurance claims when necessary to the appropriate carrier based on each payor's specific process with knowledge of timelines.
• Research, respond, and take necessary action to resolve inquiries from PSRs (Patient Service Reps), Cash Department, Charge Review, and Refund Department requests.
• Follow up via professional emails to ensure timely resolution of issues.
• Communicate with payors regarding procedure and diagnosis relationships, billing rules, payment variances, and assertively set expectations for review or change.
• Review, research, and facilitate the correction of insurance denials, charge posting, and payment posting errors.
• Follow all Managed Care guidelines using the UFJPI Payor Claims Matrix and Managed Care Matrix for each contracted plan.
• Identify and enter affected invoices on the MES (Monthly Escalation Spreadsheet) using Excel, ESM, or separate spreadsheets as needed.
• Inform Team Leader on the status of work and unresolved issues; alert Team Leader of backlogs or issues requiring immediate attention.
• Identify trended denials and report to supervisor; export data as required.
• Perform specialized billing tasks, such as contracts and grants.
• Perform special projects assigned by the Team Leader or Manager.
• Verify completeness of registration information; add and/or update as needed.
• Verify and/or assign insurance plan and code appropriately; verify and enter patient demographic information utilizing an automated billing system.
• Verify insurance coverage utilizing various online software tools.
• Complete correspondence inquiries from payors, patients, and/or clinics to provide needed information for claims resolution, including medical record requests, determining other health insurance coverage, auth requirements, questionnaires, and research of documentation and accounts.
• Collaborate with providers and other departments to obtain necessary information.
• Respond to and send emails to all levels of management in Revenue Cycle Departments, Cash Posting Department, Refunds Department, Managed Care, Referral Department, Clinics, and the CDQ Department to resolve coding and billing issues.
• Maintain timely communication to ensure all necessary action has been taken.
• Document notes in the automated billing system regarding patient inquiries, conversations with insurance companies, clinics, etc.
• Receive and make outbound calls, written or electronic communications; navigate multiple web portals and websites for insurance companies to check status and resolve outstanding claims, including status appeals, reconsiderations, and denials.
• Make outbound calls to patients to obtain correct insurance information and demographics.
• Review and interpret electronic remits and EOBs to work insurance denials and determine appropriate action needed.
• Interpret front-end rejections; determine appropriate insurance adjustments and obtain adjustment approvals as outlined in company policy.
• Verify and/or assign key data elements for charge entry such as location codes, provider numbers, authorization numbers, referring physician, CPT, ICD-10, etc.
• Work overtime as needed based on business requirements.

Requirements

• 5 years of healthcare experience in Medical Billing or related experience (required).
• Proven ability to develop coursework presentations (required).
• Ability to apply adult learning methodology in training classes/presentations (required).
• Experience with Medical Systems (preferred).
• Knowledge of CPT and ICD Coding and Medical terminology of most current versions (required).

Qualifications

• High School Diploma or GED equivalent (required).
• Bachelor’s degree in Healthcare, Finance, IT, or Education (preferred).
• Certified Professional Coder (CPC) certification (required; must be completed within 18 months of employment).

Additional Details

• Travel required: Up to 10%.
• Additional duties as assigned may vary.