The responsibility of the Revenue Cycle Claims Specialist is to maintains current knowledge of insurance carriers’ rules, regulations, and contracts; acts as a liaison for patients with the insurance carrier for internal/external customers; and is responsible for posting payments, adjustments, status, and reason codes. Contracts are reviewed for accuracy of payment with direct communication with payer provider reps. Analyze and test new system modules and upgrades. Confirmed and maintains mandated requirements for provider rosters.
Responsibilities:1. Will participate and maintain a culture within The Corvallis Clinic that is consistent with the content outlined in the Service and Behavioral Standards document. To this end, employees will be expected to read, have familiarity with, and embrace the principles contained within.
2. Researches and resolves claims based on assignment, which could include contacting payers via phone or website, contacting practices, working across departments, writing appeals, and facilitating their submission, and all other activities that lead to the successful adjudication of eligible claims including but not limited to:
Provides medical record documentation to insurance companies as requested. Files claims using all appropriate forms and attachments. Communicates with insurances companies about insurance claims, denials, appeals and payments. Research denied and improperly processed claims by contacting insurance companies or utilizing online payor portals to ensure proper processing and/or reprocessing of claims. Works directly with provider reps to escalate claims issues. Resubmits denied and improperly processed claims to insurance payers in a timely manner. Creates, reviews, and works insurance aging reports to identify unpaid insurance claims, corrects any errors, and resubmits claims as needed to ensure timely and accurate payments are received. Tasks appropriate staff while working vouchers for denials, $0 pay, and refunds. Communicates with practices and payers regarding claim denials and payer trends.
3. Collaborates with Practice Management and the co-source model within the Electronic Health Record to ensure files are kept up to date; identifies and requests support where needed:
Analyzes and tests new system modules and upgrades, providing recommendations to management staff regarding necessary modifications, education, and training. Works closely with physician credentialing to meet insurance and governmental mandates for updating insurance rosters quarterly. Responsible for maintaining and updating provider credentials, as well as updating insurance category classifications.4. Identifies root-causes of claim issues and proposes resolutions to ensure timely and appropriate payment.
5. Educates and communicates revenue cycle/financial information to patients, payers, co-workers, managers, and others as necessary to ensure accurate processes.
6. Identifies issues and or trends with payers, systems, or escalated account issues and provides suggestions for resolution to management.
7. Evaluates carrier and departmental information to determine data needed to be included in system tables.
8. Completes tasks assigned through worklists, reports, projects, team goals and objectives. Meets productivity standards as set by management.
Education/Licensure/Experience:
1. High School diploma or equivalent required.
2. Two (2) or more years of successful experience within medical billing office, required.
3. One (1) or more years of customer service experience, required.
4. Proficiency in Microsoft Office Suite; mainly Word and Excel, required.
Knowledge and Skills:1. Intermediate computer skills, including MS Word and Excel
2. Knowledge of medical terminology, CPT, ICD-9 and ICD-10 coding
3. Knowledge of finance/accounting, including insurance carrier billing
4. Excellent oral and written communication skills
5. Ability to work with difficult/upset people.
6. Ability to collaborate well with providers and other staff.
7. Ability to work on multiple tasks simultaneously in a busy, demanding environment while maintaining quality of work.