Reimbursement Specialist I - Claims

Position Summary: Performs a variety of clerical duties involving eligibility verification, claim generation, claim submission, review of unbilled accounts resolution of insurance denials and claim follow-up.

Responsibilities:

General Knowledge:

• Review unbilled accounts and move to AR to bill at appropriate time.
• Generate claims through Meditech.
• Complete requests of itemized statements and understand rules of release of information.
• Resolve account checks in assigned worklist to release claim.
• Monitor and correct combined accounts within assigned worklist.
• Correctly update insurance information the EHR (Electronic Health Record).
• Update coding information that is given at the direction of the HaysMed coding team.

Claims Clearinghouse

• Reviews and corrects pending claims or bills; and prepares claims or bills for electronic or paper submission.

• Understand ANSI errors that are generated in the claims clearinghouse and be able to resolve them prior to claim submission.
• Research payers claim acceptance trends and notify supervisor of discrepancies or updates.
• Print required information when claim in the clearinghouse gives indication that the payer only accepts paper claims.
• Complete requests of itemized statements and understand rules of release of information.
• Identify specialty claims and understand processes for those payers.
• Submit additional documentation requests when appropriate.
• Collaborate with the denials team to ensure that claims are releasing accurately.

Insurance Denials and Claims Follow Up

• Enter payor payments, adjustments, diagnosis, and accident information to appropriate accounts.
• Review daily reports of aging account receivables and collection worklists; contact insurance companies on outstanding accounts; document conversation and correspondence.
• Update demographic and insurance information in the EHR.
• Research denial, unpaid claims, and aging reports at assigned intervals.
• Maintain RTP system for claim updates and notify payer.
• Utilize payor portals for eligibility checks.

Special Claims Billing

• Specialty billing includes, but is not limited to: Hospice Billing, Abstracting, and Client Billing
• Update company demographic information as given.
• Understand split billing rules and submit claim using those specific rules.
• Using coding guidance, move codes to appropriate account.
• Utilize the EMR to determine when other services were provided to determine appropriate billing.

Appeals

• Reviews clinical information for all appeals by using criteria that is nationally recognized, in order to determine the actual necessity of the services that are requested.
• Prepares reviews for cases that do not meet the required criteria.
• Coordinate and deliver verbal and written information regarding patient and provider appeals, and ensure all letters are in line with all required standards.
• Maintains files and logs related to all appeals.
• Coordinates hearings with various internal departments and agencies.

Qualifications:

Required:

• High school diploma or equivalent is required.

Preferred:

• Satisfactory performance and one year experience
• One year of working in healthcare office setting
• Previous insurance or bookkeeping experience
• Certified Professional Biller

Infection Control: Initial and Ongoing training in dealing with infection control. Trainings could include but are not limited to, blood borne pathogens, bodily fluids and biohazardous materials as it applies to your daily work environment.

Patient Interaction: Periodic

HIPAA: This position will have access to the following Protected Health Information in order to carry out the duties related to their position at Hays Medical Center based on the following criteria:
Primary - required (routine) to do the job;
Secondary - required for the job, but mostly be exception; and
None - no approved access

Description of Information
Primary:
Patient Demographic Information (information used to identify a person): Name, Date of Birth, Address, Race, Marital Status, Religion

Clinical Information (information that describes a patient's health status): Diagnosis, Reports/Medical Notes, Test Results, Problem List, Procedures, History and Physical

Coding Information (clinical information that is in (alpha) numeric format): ICD-9 Codes, Rev Codes, CPT Codes

Financial Information/Insurance (information related to insurance, billing and payment): Billing Information, Payer Name, Payer ID, Account Balances, Plan Elements Covered, Payment Information, Payment Rate