What are the responsibilities and job description for the Claims Processor position at Unavailable?

Overview

In 2020, united in a fierce commitment to deliver the highest quality care and exceptional patient experience, Virginia Mason and CHI Franciscan Health came together as natural partners to build a new health system centered around the patient : Virginia Mason Franciscan Health. Our combined system builds upon the scale and expertise of our nearly 300 sites of care, including 11 hospitals and nearly 5,000 physicians and providers. Together, we are empowered to make an even greater impact on the health and well-being of our communities.

CHI Franciscan and Virginia Mason are now united to build the future of patient-centered care across the Pacific Northwest. That means a seamlessly connected system offering quality care close to home. From basic health needs to the most complex, highly specialized care, our patients can count on us to meet their needs with convenient access to the region’s most prestigious experts and innovative treatments and technologies.

Responsibilities

This job is responsible for submitting claims for the Franciscan Medical Group (FMG) in accordance with payer regulations and applicable guidelines. An incumbent will facilitate the overall claim process through submission of both electronic and paper-based claims, resolution of claim-form edits and validation of data integrity.

An incumbent also serves as a resource to other staff and departments for clinic billing through validation that proper billing guidelines are being adhered to.

Work requires an understanding of detailed billing requirements, claims attachments and claim rejections, as well as attention to detail, the ability to accurately and timely troubleshoot / resolve questions / issues and to resolve (within scope of the position) issues which may have a potential impact on revenues.

Essential job functions :

Transmits / retrieves electronic patient claims / files to and from the claims clearinghouse in accordance with established procedures.

Reviews claims for all necessary requirements for billing, including complete patient and insurance information; completes paper claim processing in a timely and accurate manner.
Resolves all claim edits, in both the billing system and the clearinghouse, accurately and timely through attention to detail and critical thinking skills in accordance with payer regulations and guidelines.
Notifies Supervisor of claim edits that could be reduced / eliminated through system modifications and / or communication and feedback to the department / clinic or other areas.
Notifies Supervisor of additional claim edits that when added may reduce denials and result in prompt payment for the organization.
Notifies Supervisor of claim submission requirement changes and electronic billing errors.
Completes payer specific edits using knowledge of payer reimbursement methodologies or government regulations.

Identifies and researches unusual, complex or escalated issues as assigned; applies problem-solving and critical thinking skills as necessary to resolve issues within the scope of position authority.

Notifies Supervisor / Manager of other ongoing issues and concerns.

Documents all activities and findings in accordance with established policies and procedures; ensures the integrity of all account documentation; maintains confidentiality of medical records.

Meets quality assurance and productivity standards for timely and accurate claim submission in accordance with organizational policies and procedures.

Maintains current knowledge of internal, industry, and government regulations as applicable to assigned function.

Applies current knowledge of detailed billing requirements, claim attachments and rejections.

Has knowledge of, and is compliant with, government regulations including "signature on file" requirements, compliance program, HIPAA, etc.

Establishes and maintains professional and effective relationships with peers and other stakeholders.

Establishes and maintains a professional relationship with payers and FMG staff in order to resolve issues.

Depending on role and Epic training, may be called upon to support other areas in the Revenue Cycle.

Performs related duties as required.

Qualifications

Education / Work Experience Requirements

Two years of revenue cycle or related work experience that demonstrates attainment of the requisite job knowledge and abilities; OR

Post-high school education in a field (e.g. medical billing) that would demonstrate attainment of the requisite job knowledge / abilities may be substituted, on a month-for-month basis, for one year of the experience requirement.

Job Knowledge / Abilities

Knowledge of general concepts and practices that relate to the healthcare field, and specific policies, standards, procedures and practices that pertain to the assigned function.

Knowledge of the claim submission process for electronic and paper-based claims.

Knowledge of clinic operations related to patient registration, referrals and cash collections.

Knowledge of general office principles, practices, standards, systems and tools / equipment.

Knowledge of medical insurance, payer contract, and basic medical terminology and abbreviations.

Knowledge of the regulatory / reporting requirements that pertain to the assigned function.

Knowledge of sources and availability of information relevant to the assigned function.

Knowledge of the operation and application of automated systems applicable to the assigned function.

Ability to understand and apply detailed billing requirements, claim attachments and claim rejections.

Ability to enter data in accordance with established standards of timeliness, accuracy and productivity.

Ability to keep abreast of trends, developments and changing regulatory requirements that impact matters within designated scope of responsibility.

Ability to identify and articulate non-compliance with established guidelines and / or regulatory requirements.

Ability to troubleshoot, understand and / or adapt moderately complex oral and or written instructions / guidelines to diverse or dissimilar situations.

Ability to maintain confidentiality of medical records, and to use discretion with confidential data and sensitive information.

Ability to demonstrate attention to detail and critical thinking skills within the context of the assigned function, with a commitment to accuracy.

Ability to effectively prioritize and execute tasks while under pressure.

Ability to make decisions based on available information and within the scope of authority of the position.

Ability to demonstrate excellent customer service skills, including professional telephone interactions.

Ability to read, understand and communicate in English sufficient to perform the duties of the position.

Ability to establish and maintain effective working relationships as required by the duties of the position.

Ability to use office equipment and automated systems / applications / software at an acceptable level of proficiency.

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