Springfield, IL, USA
Analyzes, investigates, and resolves claims/billing information and/or errors associated with the more complex inpatient/outpatient medical insurance claims. Ensures compliance with managed care guidelines and MMC organizational policies
Receives and examines daily listings for assigned billing claims and determines which require further analysis and action.
Investigates assigned billing claims with incomplete/incorrect information and resolves the more complex problems or errors to ensure complete and compliant information accompanies the claim.
Prioritizes claims based on specified criteria and files the claim, either electronically or via paper claim. Ensures careful adherence to insurance guidelines, timeliness, accuracy, and processing procedures.
Researches and resolves complex issues associated with patient insurance accounts. As applicable, identifies, documents, and reports problematic trends to management.
Analyzes reports containing rejected account information and performs the necessary research to resolve the reason(s) for the rejection and secures any other required information.
Provides input regarding system edits designed to identify and ensure consistent and compliant data necessary for processing medical insurance claims.
Responds to requests from internal departments regarding the proper coding, billing, and processing of medical insurance claims.
Communicates and resolves issues with a variety of internal and external sources regarding medical insurance claims. This may include internal departments, patients (or other responsible parties), third-party payors, social service agencies, Medicare/Medicaid staff, other insurance carriers, service providers, and collection agencies.
Initiates corrections to charges and contractuals / allowances within scope of expertise and authority granted.
Identifies and researches the appropriateness of late charges and, as necessary, adjusts the charge / patient account based on research findings
Identifies and calculates write-off amounts and secures the necessary approvals from management for processing.
Documents online systems and electronic files to ensure accurate data is noted regarding the status of claims and payments.
Ensures compliance to managed care contract guidelines and processes at each work step to facilitate accurate and timely reimbursements to the organization.
May assist with special projects, analyses, or audits.
As directed and defined by management, orients and cross-trains on other unit duties which are outside of regularly assigned area of responsibility. May serve as a back-up for other areas within the unit or department, especially during times of special needs or staff absences.
Performs other related work as required or requested.
The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job. Incumbents may be requested to perform tasks other than those specifically presented in this description.
Education equivalent to graduation from high school or GED is required.
Two or more years as a Billing Specialist (or comparable medical claims/billing experience), with the technical knowledge to process all types of applicable claims and resolve errors and complex issues associated with them.
Demonstrates thorough knowledge of medical terminology, medical procedural (CPT) and diagnosis (ICD-9 CM) coding, and hospital billing claim form UB04 is required.
Demonstrates a comprehensive knowledge of the electronic billing system and key contract billing guidelines and possess the ability to train others on the entire billing process.
Basic working knowledge of personal computers and their associate user software is required. Experience with Microsoft Office products Word and Excel is preferred.
Ability to work within the guidelines of defined managed care contract policy provisions and company procedures.
Demonstrates ability to work successfully with internal customers and external contacts is required.
Possesses a highly-developed detail orientation, critical thinking, and problem solving ability.
Demonstrates excellent oral and written communication, keyboarding, and basic math skills.
Demonstrates ability to work unsupervised as well as the ability to work in a group setting.