Follow-up with insurance carriers, include Medicaid/Medicare, to facilitate appropriate reimbursement for Children's hospital and physician services. Investigate reasons for non-payment and collect information and provide necessary documentation to insurance carriers. Write letters of appeal to support payment of denied claims. Document activities and contacts in systems. Develop detailed understanding of assigned managed care contractor and payor requirements. Track and report payment trends with assigned carriers.
Qualifications:Minimum Education High School Diploma or GED (Required)
Minimum Work Experience1 year Experience in hospital/physicians collections (Required)
Required Skills/KnowledgeKnowledge of billing with a third party payorsCPT/HCPS codes ICD 9/10 Microsoft 2010 Intermediate ExcelAbility to multitaskDevelop knowledge of internal billing systems to research denials, appeals and follow-up action.Excellent Customer Service Skills.
Functional AccountabilitiesAppeal Process for Denied Claims - Receive denial correspondence from insurance companies via mail or payment posting process indicating that claims are not being paid, may be electronic or paper format; evaluate type of denial using codes and prioritize work based on size of claim and likelihood of payment.
- Proactively follow-up on submitted claims to determine payment status through telephone or web contact in a timely manner.
- Research reason for denial and collect more information and documentation: review system records to identify source of denial; contact Clinic Operations staff, Utilization Management department and Health Information Management department to collect necessary information and documents, e.g., referrals, authorizations for appeal.
- May recommend adjustments and write-offs to bill within identified parameters; refer to manager as appropriate; with required documents, write timely appeals for payment.
- Manage large volume of denials to maximize reimbursement.
Follow-Up Submitted Claims - Check for payment posting and receive list of unpaid claims from system.
- Proactively follow-up on submitted claims to determine payment status through telephone or web contact in a timely manner; collect information from carriers about what specific documentation is needed to pay claim; contact internal departments (Health Information Management, Clinic Operations) to information and documentation to carrier to facilitate claim payment; provide documentation via fax, phone or mail to payer, e.g., operative reports.
- Track appeals of denied claims to determine status and work with carrier for payment; Resubmit claim if payor does not have record of claim.
- Prioritize work to facilitate payment of higher account balances.
- May follow-up with parent if insurance has paid parent to receive reimbursement.
- May recommend adjustments and write-offs to bill within identified parameters; refers to manager as appropriate; Document actions in system including contact with payors, appeals sent, research findings, write-offs, documentation sent etc.
Tracking T rends - Identify and report trends in denied and appealed claims to manager and work collaboratively to identify appeal and follow-up strategy inresponse to trends.
Safety - Speak up when team members appear to exhibit unsafe behavior or performance
- Continuously validate and verify information needed for decision making or documentation
- Stop in the face of uncertainty and takes time to resolve the situation
- Demonstrate accurate, clear and timely verbal and written communication
- Actively promote safety for patients, families, visitors and co-workers
- Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance
Organizational AccountabilitiesProgram Knowledge - Understand managed care contracting requirements and apply principles for assigned payors.
- As assigned, develop detailed understanding of state/federal assistance programs, e.g., Medicaid.
- Understand federal and state regulations surrounding payment denials and appeals as it applies to assigned payors.
Organizational Commitment/Identification - Partner in the mission and upholds the core principles of the organization
- Committed to diversity and recognizes value of cultural ethnic differences
- Demonstrate personal and professional integrity
- Maintain confidentiality at all times
Customer Service - Anticipate and responds to customer needs; follows up until needs are met
Teamwork/Communication - Demonstrate collaborative and respectful behavior
- Partner with all team members to achieve goals
- Receptive to others' ideas and opinions
Performance Improvement/Problem-solving - Contribute to a positive work environment
- Demonstrate flexibility and willingness to change
- Identify opportunities to improve clinical and administrative processes
- Make appropriate decisions, using sound judgment
Cost Management/Financial Responsibility - Use resources efficiently
- Search for less costly ways of doing things