Medical Claims Research Specialist

POSITION / JOB SUMMARY :

The Accounts Research Specialist are responsible for accounts research of physician services by researching denials for resolution and providing customer service to patients, insurance companies, third parties, providers and their offices. The employee will appeal denials appropriately, identify and report denial trends to management, notating on guarantor / patient accounts of research and resolution of claim(s), resolve insurance and patient credits, answer and resolve account inquiries, and handle secondary insurance claims process.

KEY RESPONSIBILITIES & DUTIES :

• Research and resolve all types of denials efficiently and accurately, which includes but not limited to coordination of benefits (COB), insurance eligibility, coding (e.g., modifiers, diagnoses, CCI edits), billing (e.g., NPI, POS, DOS).
• Research and resolve insurance and patient credits timely and accurately.
• Follow insurance appeal standards or protocols, establish an appeal correspondence to petition the denial as incorrect or inappropriate and for the third-party carrier to reconsider and adjudicate the claim correctly. May inquire with assigned coder for education or letter of appeal, if outside the scope of the AR Specialist.
• Document all actions and communications taken regarding each account / session / encounter in the designated fields in the practice management system (PMS).
• Identify and track denial trends by payer, provider, and code.
• Identify billing-related issues and work with appropriate internal teams to resolve the identified issue(s) in a timely manner.
• Must stay up to date with industry trends and changes that impact Accounts Researching. This may include seminars, training, and reading material. It is the employee's responsibility to maintain one's AR knowledge and learn specific required areas, such as basic coding.
• Ensure secondary claims are filed with the appropriate primary insurance EOB attachment in a timely and accurate manner.
• Answer customer service inquiries professionally, timely and efficiently. Make certain the inquiry is completed, closed or followed up on until closure happens. Document the guarantor / patient's account in detail.
• Handle and expedite distinctive cases include bankruptcy, charity, statements, tax billing document, refunds and other items, should be processed accurately but expeditiously and follow-through. Follow the designated processes for these distinctive cases.
• Collect outstanding balances must be done professionally and with tact. Posting of payment done accurately, timely and according to protocol.
• Handle all claim denials appropriately and according to department standards.
• Other duties as assigned.

KNOWLEDGE, SKILLS, AND ABILITIES

CREDENTIALS / EDUCATION / EXPERIENCE