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. Hours are 11:00 a.m. to 8:00 p.m. Monday - Friday. 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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