Job Description

Position Summary

The Call Processing Reimbursement Specialist I is responsible for the complete revenue cycle including billing medical, dental and/or hospital claims, and working directly with members over the phone. They are responsible for the follow-up performed on insurance balances to ensure reimbursement is accurate and received timely. They are also responsible the self-pay collections after insurance and answering billing related questions.

Essential Functions of the Job:

• Demonstrates knowledge and understanding of the San Ysidro Health services and programs to answer questions and direct calls appropriately
• Review, collect and update patient demographics and take appropriate actions to update changes identified
• Efficiently and actively provides excellent customer service by properly greeting, listening, assisting, directing, and closing each call
• Understands, recognizes, and effectively handles unique medical issues, urgent services and patient grievances and follows established protocols to resolve problems or determines escalation to supervisor
• Log in and be ready to receive or make calls as directed by schedule as well as utilizing break codes appropriately as defined by the call management system
• Provides quality, efficient telephone customer service to internal and external customers and route calls to appropriate department for continued assistance as necessary
• Clearly and effectively communicates with patient/staff via call or electronic message. Takes complete messages that are detailed, concise, spelled accurately and utilize correct medical terminology
• Responds to all patient or insurance telephone inquiries to ensure timely reimbursement
• Prepares accounts and encounters for accuracy for billing. Prepare, review, and transmit claims using automated systems and manual paper claim process
• Provides any required attachments to third party claims including authorizations and EOB'S to ensure timely payment for the third-party payer
• Changes system financial settings once primary insurance has paid to ensure that co-payments and deductibles are generated to guarantors
• Identify and bill secondary payers
• Ensures accurate calculation of disallowances and adjustments through analysis of SYHealth contracts, Medicare and Medi-Cal reimbursement schedules and rates
• Performs adjustment write off(s) keying and posting via computer input after obtaining approval signatures if required
• Performs timely follow up and appeals on unpaid claims using the system work list and/or Remittance Advices, EOBs, and other payment documents
• Documents all analysis findings, phone calls and correspondence in the online practice management system
• Must maintain assigned Accounts Receivable at or below goal on a consistent basis
• The Call Processing Reimbursement Specialist is required to compose professional written correspondence with all internal & external entities
• Attends meeting and training classes as required by departmental or facility management
• Will be called upon to perform special projects and participate in internal and external audits that may require some evening and weekend hours
• Adheres to established departmental and facility policy and procedures, objectives, quality assurance programs, safety, and infection control standards

Additional Duties and Responsibilities:

• Performs other duties as assigned by the Director of Revenue Cycle, Business Office Manager or Billing Supervisors

Job Requirements

Experience Required:

• Minimum of 1 years’ experience in a medical billing department
• Must also demonstrate knowledge of CPT, HCPCs, and ICD-10 coding as well as Medical Terminology

Education Required:

• High School Diploma or GED equivalent

Verbal and Written Skills Required to Perform the Job:

• Bilingual English/Spanish required
• Good oral and written communication skills
• Provides positive customer service skills
• Must possess the ability to communicate effectively in English; both verbally and in all written communication

Technical Knowledge and Skills Required to Perform the Job:

• Experience in billing, CPT codes, and ICD-10, as well as medical terminology
• Must be able to work independently
• Experience and knowledge with Microsoft Office software
• Math ability to calculate and accurately analyze various accounts

Equipment Used:

• General office equipment to include PC and Software (Excel, Word, Office), phone, fax, etc.

Working Conditions and Physical Requirements:

• Sedentary work requires sitting and use of the PC most of the day

Universal Requirements:

Pre-employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs. Compliance with all mandated vaccinations and all boosters is a term and condition of employment.

About Us San Ysidro Health is a Federally Qualified Health Care organization committed to providing high quality, compassionate, accessible and affordable healthcare services for the entire family. The organization was founded by seven women in search of medical services for their families and community. Almost 50 years later, San Ysidro Health now provides innovative care to over 108,000 patients through a vast and integrated network of 47 program sites across the county. San Ysidro Health could not serve our patients without the dedication of our passionate and hardworking employees. Apply today and become a part of our mission-driven team! San Ysidro Health has a long-standing commitment to equal employment opportunity for all applicants for employment. Employment decisions including, but not limited to, those such as employee selection, performance evaluation, administration of benefits, working conditions, employee programs, transfers, position changes, training, disciplinary action, compensation, and separations are made without regard to race, color, religion (including religious dress and grooming), creed, national origin, nationality, citizenship status, domestic partnership status, ancestry, gender, affectional or sexual orientation, gender identity or expression, marital status, civil union status, family status, age, mental or physical disability (including AIDS or HIV-related status), atypical heredity cellular or blood trait of an individual, genetic information or refusal to submit to a genetic test or make available the results of a genetic test, military status, veteran status, or any other characteristic protected by applicable federal, state, or local laws.