Overview

Reviews and audits claims for billing, coding, services and other compliance or reimbursement issues. Assists with non-clinical aspects of the claims review process and benefit design/coding Works under general supervision.

Responsibilities
Reviews, investigates and adjudicates claims for medical and non-medical services that involve the application of contractual provisions in accordance with provider contracts and authorizations.Communicates and follows up with a variety of internal and external sources including but not limited to providers, members, attorneys, regulatory agencies and other carriers on any claim related matters.Assigns appropriate ICD10-CD, HCPCS and CPT codes as well as other codes necessary to process claims based on claim information submitted.Keeps current on new coding and billing guidelines and federal and state initiatives regarding claims.  Educates other departments on new/changes to regulations. Attends meetings with providers to assist in communicating proper billing procedures, as appropriate.Reviews patient records for necessary documentation and completeness.  Records and reconciles documentation deficiencies by notifying the individuals responsible.Coordinates recoupment efforts with Revenue Cycle Department/Finance that are the result of billing errors and overpayments. Responds to inquiries regarding recoupments.Schedules patients’ medical visits with Nurse Practitioner and other clinicians, as needed.Performs patient registration, as neededPerforms insurance eligibility checks and initial and ongoing visit authorization prior to for care being provided.  Communicates with clinicians as needed.Supports the department’s call management strategy.  Coordinates with answering calls to provide follow up and follow through on all clinical and operational communications.Generates daily, monthly and quarterly reports used for managing process timeframes and vendor productivity. Participates in special projects and performs other duties, as assigned.
Qualifications

Education:Bachelor’s Degree or the equivalent work experience required

Experience:   Minimum of two years claims processing experience required. Knowledge of Medicare claims submission rules and coding experience required. Proficient PC skills, including Microsoft Windows required. Knowledge of HIPAA guidelines required.  Excellent communication and analytical skills also required.