Overview
Responsible for obtaining appropriate reimbursement for Accounts Receivables for professional services of patients seenin physician offices, out-patient hospital, in-patient hospital, ASC, urgent care, ER, off-site hospitals and Telehealthlocations while maintaining timely claims submissions. Registers patients and completes necessary documentationincluding insurance verification and benefits determination. Research charges to submit to appropriate carrier according toFederal/Managed Care rules, regulations and compliance guidelines. Review codes using CPT, ICD10, HCPCS and CCIguidelines to ensure compliance with institutional compliance policies for coding and claim submission. Enter and billprofessional charges into automated billing system program. Utilize resources and tools in the resolution of invoicesfollowing company policy for assigned payor/s. Resolving outstanding balances with internal and external communicationwith customers.
Responsibilities
Triage invoices and determine appropriate action andcomplete the process required to obtain reimbursement for alltypes of professional services by physicians and nonphysicianproviders maintaining timely claims submissionsand timely Appeals processes as defined by individualpayors.
Resubmit insurance claims when necessary to theappropriate carrier based on each payor's specific processwith the knowledge of timelines.
Research, respond and take necessary action to resolveinquiries from PSRs (Patient Service Reps), CashDepartment, Charge Review and Refund Departmentrequests. Follow-up via professional emails to ensure timelyresolution of issues
Must be comfortable and knowledgeable speaking withpayors regarding procedure and diagnosis relationships,billing rules, payment variances and have the ability toassertively and professionally set the expectation for reviewor change.
Review, research and facilitate the correction of insurancedenials, charge posting and payment posting errors.Follow all Managed Care guidelines using the UFJPI PayorClaims Matrix and Managed Care Matrix for each contractedplan
Identify and enter affected invoices on the MES (MonthlyEscalation Spreadsheet) using Excel, ESM or separatespreadsheets that may be needed
Inform Team Leader on the status of work and unresolvedissues. Alert Team Leader of backlogs or issues requiringimmediate attention
Identify trended denials and report to supervisor, exporttrended/unpaid invoices on Excel t to track and provide tosupervisorMust be knowledgeable of specialized billing, i.e. contractsand grantsPerform special projects assigned by the Team Leader orManagerVerify completeness of registration information. Add and/orupdate as needed. Verify and/or assign insurance plan andcode appropriately. Verify and enter patient demographicinformation utilizing automated billing system. Verifyinsurance coverage utilizing various online software tools.Ability to work overtime as needed based on the needs of thebusiness
Complete correspondence inquiries from payors, patientsand/or clinics to provide the needed information for claimsresolution. This can include medical record requests,determining if other health insurance coverage exists, authrequirements, questionnaires, research of the documentationand accounts, communicate with the clinics for additionalinformation needed, collaborate with providers and otherdepartments to obtain necessary information.
Respond and send emails to all levels of management in theRevenue Cycle Departments, Cash Posting Department,Refunds Department, Managed Care, Referral Department,Clinics and the CDQ Department to resolve coding and billingissues. Maintain timely communication to ensure allnecessary action has been taken.
Documents notes in the automated billing system regardingpatient inquiries, conversations with insurance companies,clinics, etc. for all actions.
Receive and make outbound calls, written or electroniccommunications, navigate multiple web portals and websitesto insurance companies for status and resolution ofoutstanding claims. Status appeals, reconsiderations anddenials.
Make outbound calls to patients to obtain correct insuranceinformation and demographics
Review and interpret electronic remits and EOB's to workinsurance denials to determine appropriate action needed.Interpret front end rejections. Determine appropriateinsurance adjustments and obtain adjustment approvals asoutlined in the company policy.
Verify and/or assign key data elements for charge entry suchas, location codes, provider #'s, authorization #'s, referringphysician, CPT, ICD-10, etc.