Minimum Education

High School Diploma or GED (Required)

Minimum Work Experience
1 year Experience in hospital/physicians collections (Required)

Required Skills/Knowledge
Knowledge of billing with a third party payors
CPT/HCPS codes ICD 9/10 Microsoft 2010 Intermediate Excel
Ability to multitask
Develop knowledge of internal billing systems to research denials, appeals and follow-up action.
Excellent Customer Service Skills.

Functional Accountabilities
Appeal Process for Denied Claims

• Receive denial correspondence from insurance companies via mail or payment posting process indicating that claims are not being paid, may be electronic or paper format; evaluate type of denial using codes and prioritize work based on size of claim and likelihood of payment.

• Proactively follow-up on submitted claims to determine payment status through telephone or web contact in a timely manner.

• Research reason for denial and collect more information and documentation: review system records to identify source of denial; contact Clinic Operations staff, Utilization Management department and Health Information Management department to collect necessary information and documents, e.g., referrals, authorizations for appeal.

• May recommend adjustments and write-offs to bill within identified parameters; refer to manager as appropriate; with required documents, write timely appeals for payment.

• Manage large volume of denials to maximize reimbursement.

Follow-Up Submitted Claims

• Check for payment posting and receive list of unpaid claims from system.

• Proactively follow-up on submitted claims to determine payment status through telephone or web contact in a timely manner; collect information from carriers about what specific documentation is needed to pay claim; contact internal departments (Health Information Management, Clinic Operations) to information and documentation to carrier to facilitate claim payment; provide documentation via fax, phone or mail to payer, e.g., operative reports.

• Track appeals of denied claims to determine status and work with carrier for payment; Resubmit claim if payor does not have record of claim.

• Prioritize work to facilitate payment of higher account balances.

• May follow-up with parent if insurance has paid parent to receive reimbursement.

• May recommend adjustments and write-offs to bill within identified parameters; refers to manager as appropriate; Document actions in system including contact with payors, appeals sent, research findings, write-offs, documentation sent etc.

Tracking T rends

• Identify and report trends in denied and appealed claims to manager and work collaboratively to identify appeal and follow-up strategy inresponse to trends.

Safety

• Speak up when team members appear to exhibit unsafe behavior or performance

• Continuously validate and verify information needed for decision making or documentation

• Stop in the face of uncertainty and takes time to resolve the situation

• Demonstrate accurate, clear and timely verbal and written communication

• Actively promote safety for patients, families, visitors and co-workers

• Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance

Organizational Accountabilities
Program Knowledge

• Understand managed care contracting requirements and apply principles for assigned payors.

• As assigned, develop detailed understanding of state/federal assistance programs, e.g., Medicaid.

• Understand federal and state regulations surrounding payment denials and appeals as it applies to assigned payors.

Organizational Commitment/Identification

• Partner in the mission and upholds the core principles of the organization

• Committed to diversity and recognizes value of cultural ethnic differences

• Demonstrate personal and professional integrity

• Maintain confidentiality at all times

Customer Service

• Anticipate and responds to customer needs; follows up until needs are met

Teamwork/Communication

• Demonstrate collaborative and respectful behavior

• Partner with all team members to achieve goals

• Receptive to others’ ideas and opinions

Performance Improvement/Problem-solving

• Contribute to a positive work environment

• Demonstrate flexibility and willingness to change

• Identify opportunities to improve clinical and administrative processes

• Make appropriate decisions, using sound judgment

Cost Management/Financial Responsibility

• Use resources efficiently

• Search for less costly ways of doing things