MINIMUM QUALIFICATIONS:
- High school diploma or General Equivalency Diploma (GED); or equivalency of education and years of experience
are acceptable.
- College or certification course work, preferred.
- 1-2 years of experience in medical claims required. Behavioral health knowledge preferred.
- Ability to obtain and maintain Level One fingerprint clearance and meet agency personnel requirements
JOB SUMMARY (INCLUDING, BUT NOT LIMITED TO)
Responsible for the payment & collection process for agency billed claims:
a) Performs full cycle billing and collections functions which includes a complex review of billing and
collection activities.
b) Interpret and analyze EOBs, remits and payment posting entries.
c) Check claim status from payers through telephone, websites, and any other communication deemed necessary for insurance carriers in a prompt and efficient manner.
d) Collect on insurance accounts by contacting insurance carriers and other third-party payers to verify receipt of billing and other information needed to process claims, secure approximate date of payment, negotiate with
claims personnel for prompt payment and resolve discrepancies in billing within appropriate time frames.
e) Categorize and quantify payer payment issues for resolution and reporting to Rev Cycle Manager.
f) Review and interpret explanation of benefits to determine contractual compliance, accuracy of payment
received, true patient responsibility, status of denied or reduction of service coverage and follow up
appropriately.
g) Researches, identifies and rectifies any special circumstances resulting in delayed payments.
h) Works aggressively with health plans regarding accounts that have aged over 30, 60 and 120 days
i) Research claims that have been paid incorrectly and ensure prompt payment.
j) Collaborate effectively with, Rev Specialist I, Billing Coordinator & Payer in a timely manner to resolve billing
problems and disputes.
k) Monitors the billing and collection electronic charge entry processes to ensure days in accounts receivable
comply with department standards.
Responsible for back-end claim processing and denial reconciliation:
a) Responsible for posting all third-party payments, denials and adjustments.
b) Provide all necessary follow-up including collections on outstanding claims via payor websites and IVR systems.
c) Investigates denials and verifies completeness and accuracy of program billing by collaborating and consulting with assigned Campus staff.
d) Reconciles claims submission with payments and denials as reflected on an Explanation of Benefits and resubmits denied claims within 30 days of receipt.
e) Draft correspondence to payers including 1st level appeals for technical denials, and corrected claim memos.
f) Works with Billing Coordinator to properly route adjudicated statuses that cannot be entered into PM System.
g) Reviews accounts receivable activities and calls on outstanding balances or claims.
h) Routinely research payer credit balances and regularly writes up request for refunds.
i) Manage EPM worklists and reports from TS for the reconciliation of unpaid or denied claims.
j) Works closely with Department Leadership and Credentialing Department to troubleshoot contract and
provider credentialing issues which have resulted in unpaid, denied or short pay claims.
k) Ensures timely and proper reimbursements by researching and resolving all aged receivables.
l) Performs basic Payer contract management assessing payer performance and payment accuracy according to contractual language.