Job description

Job Description

Please note: This position comes with a $3,500 sign on bonus

Job Summary:

This position reviews known denial activity, whether electronically-generated or via paper, and reviews those denials, identifying the core issue involved (claims, account, secondary, enrollment, etc.), and adjudicates the daily/weekly/monthly procurement of outbound claims to health plans. As part of this role, steps are taken to assure that unbilled claims are moved into a billed status and those claims are both HIPAA-compliant and accurate, fairly representing the service provided by the organization. This role also identifies routine errors on claim forms referring to management for action This position then takes action to correct the known denial activity as well as take steps to prevent similar denials from occurring. Due to the complexity of denial prevention, this position will often identify cases and refer those to senior leadership to partner on solutions to denied claims.

Essential Functions:

• “Scrub” claims to ensure that procedure(CPT/HCPCS, diagnosis, place of service, rendering provider and modifier codes are present and accurate and that necessary patient, provider, and visit information is complete and correct.
• Ensure timely medical billing for each assigned treatment center.
• Transmit 837P & 837I EDI files/claims directly to the payer or use a third-party organization, such as a clearinghouse. Under HIPAA, providers must submit their claims electronically using the ASC X12 standard transmission format, commonly known as HIPAA 5010.
• Identify any returned claims from clearinghouse systems, commonly known as “front-end rejections”; when a claim is not further adjudicated by the health plans.
• Correct and resubmit the rejected claims in the clearinghouse system, make the appropriate system updates to the host database so that data integrity is preserved, to allow the entry of the claim into the payer adjudication system.
• Process remittance advice. Import 835 EDI files to reconcile and post payments for Third Party Insurance.
• Identifies accounts that are denied from health plans.
• Follow up on unpaid claims in a timely manner, and report problem accounts to the Account Receivable Supervisor.
• Run A/R Reports
• A/R within 30 days is the golden standard.
• Monitors claims and requests for documentation on a weekly basis to determine additional action.
• Assists intake with authorizations and obtaining physician orders.
• Reconcile and resolve all discrepancies ensuring all activity is posted to the respective accounts.
• Rebill claims when required and do so in accordance with Payer Billing Guidelines in effect on the day that service is rebilled.
• Achieve RCM KPI Metrics:

• Current days in accounts receivable (A/R)
• Clean claims rate
• Aging percentages
• Clearinghouse rejection count
• Provider revenue summary
• Service analysis report
• Keeps lines of communication open with the Clinic Operations Team to ensure individualized goals are met.
• Adheres to the service policy and principles of CMG/ New seasons.
• Other duties as assigned.

Supervisory Responsibilities:

(This position will supervise non-exempt staff in support roles performing duties described in "Essential Functions".)

None.

Essential Qualifications:

(To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the competencies (minimum knowledge, skill, and ability) required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions).

Education/Licensure/Certification:

The position requires a high school diploma or GED.

Required Knowledge:

The ideal candidate is familiar with healthcare claims data and the Revenue Cycle components necessary to generate claims. Also familiar with 837 claim form formats (1500 and UB) and with common terminology for denied claims and will have been trained on zero pay items in accordance with the department's training tool for the same.

Experience Required:

This position requires a minimum of 2+ years experience in healthcare roles where they have been associated with claim data and claim production, as well as account follow up and denial processing.

Skill and Ability:

The ideal candidate is familiar with the healthcare management, billing environment and the Revenue Cycle components that lead to claim generation and payment, as well as account follow up. Ability to work effectively on a team, coordinate assignments and meet client goals in a fast pace environment. Strong organization skill and attention to detail. Excellent computer skills, and efficient in Microsoft Office Suite. Must be able to listen in order to process information, and communicate effectively; provide guidance and support, be trustworthy, and delegate appropriately; think creatively and adjust to circumstances; build relationships in order to facilitate team success; work efficiently and competently; be able to take action in order to achieve results; cultivate and motivate.

Job Type: Full-time

Pay: From $22.00 per hour

Schedule:

• 8 hour shift
• Monday to Friday

Work Location: One location

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