Under the general supervision of the Reimbursement Supervisor / Manager, is responsible for various reimbursement functions, including but not limited to accurate and timely claim submission, claim status, collection activity, appeals, payment posting, and/or refunds, until accounts receivable issues are properly resolved. PRIMARY DUTIES AND RESPONSIBILITIES:
Qualifications: EXPERIENCE AND EDUCATIONAL REQUIREMENTS:
- Collects and reviews all patient insurance benefit information, to the degree authorized by the SOP of the program.
- Provides assistance to physician office staff and patients to complete and submit all necessary insurance forms and program applications.
- Completes and submits all necessary insurance forms and electronic claims to process the claims in a timely manner as required by all third party payors. Researches and resolves any electronic claim denials.
- Researches and resolves any claim denials or underpayment of claims.
- Effectively utilizes various means for collections, including but not limited to phone, fax, mail, and online methods.
- Provides exceptional customer service to internal and external customers; resolves any customer requests in a timely and accurate manner; escalates complaints accordingly.
- Maintains frequent phone contact with provider representatives, third party customer service representatives, pharmacy staff, and case managers.
- Reports any reimbursement trends/delays to supervisor (e.g. billing denials, claim denials, pricing errors, payments, etc.).
- Processes any necessary insurance/patient correspondence.
- Provides all necessary documentation required to expedite payments. This includes demographic, authorization/referrals, National Provider Identification (NPI) number, and referring physicians.
- Coordinates with inter-departmental associates to obtain appropriate medical records as they relate to the reimbursement process.
- Maintains confidentiality in regards to patient account status and the financial affairs of clinic/corporation.
- Communicates effectively to payors and/or claims clearinghouse to ensure accurate and timely electronically filed claims.
- Works on problems of moderate scope where analysis of data requires a review of a variety of factors. Exercises judgment within defined standard operating procedures to determine appropriate action.
- Typically receives little instruction on day-to-day work, general instructions on new assignments.
- Performs related duties as assigned.
Requires broad training in fields such as business administration, accounting, computer sciences, medical billing and coding, or similar vocations generally obtained through completion of a two year associate's degree program, technical vocational training, or equivalent combination of experience and education. Two (2) years directly related and progressively responsible experience preferred. MINIMUM SKILLS, KNOWLEDGE AND ABILITY REQUIREMENTS:
- Ability to communicate effectively both orally and in writing.
- Ability to build productive internal/external working relationships.
- Strong interpersonal skills.
- Strong negotiating skills.
- Strong mathematical skills.
- Strong organizational skills; attention to detail.
- General knowledge of accounting principles, pharmacy operations, and medical claims.
- General knowledge of HCPCS, CPT, ICD-9 and ICD-10 coding preferred.
- Global understanding of commercial and government payers preferred.
- Ability to proficiently use Microsoft Excel, Outlook and Word.
- Is developing professional expertise; applies company policies and procedures to resolve a variety of issues.
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