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Claims Specialist - Centreal Billing Office - Full Time

Company: Saint Joseph Health System
Location: South Bend
Posted on: June 14, 2019

Job Description:

Minimum $14.97 - Maxmum $21.70 JOB SUMMARY Serves as a primary resource to Claims Processors and special projects, research, testing and training. Supports supervisory activities through staff monitoring and development. Acts as liaison with outsource partners, provider representatives and other outside agencies in addressing management of the accounts receivable. Supports the preparation and submission of compliant claims for optimal reimbursement on patient accounts. Analyzes outstanding accounts receivable and takes appropriate action to identify and resolve issues preventing, delaying, or reducing appropriate payment through systemic or staffing changes. Responds to inquiries and requests from various sources related to patient accounts and account processing. Researches and resolves higher level systemic and global payer issues impeding timely processing and optimal reimbursement of claims. Performs all duties according to department and hospital procedures. JOB DUTIES 1.--Actively demonstrates the organization's mission and core values, and conducts oneself at all times in a manner consistent with these values. 2.--Knows and adheres to all laws and regulations pertaining to patient health, safety and medical information. 3.--Coordinates accounts receivable processing within the team, other areas of the department, and other departments within the organization to provide seamless revenue cycle processing for optimal reimbursement. Assists supervisor in interviewing job candidates, providing input on team performance and productivity reporting, and participates in documenting performance appraisal. Maintains time and attendance records for team members in accordance with organization's policies to assure appropriate staffing levels. Facilitates orientation and assists in the training of new employees or team members needing improvement. 4.--Assures claims are reviewed for irregularities, and edited for accuracy and completeness. Reviews electronic edit information and makes recommendations for changes in legacy and claims submission systems. Ensures claims meet all payer requirements for submission. Coordinates claim submission on a timely basis, including any attachments and additional documentation. 5.--Manages and maintains unbilled claim inventory at minimum level through analysis and resolution of edits. Resolves issues promptly through edit development, communication with related departments and external resources in order to submit all claims on a timely basis. 6.--Identifies and resolves issues related to claim components, such as erroneous or late charges, dates of service, billing codes and claim formatting. Documents and refers issues of concern to Supervisor. 7.--Reviews payer bulletins, manuals, and newsletters. Stays abreast of current claim requirements and disseminates changes to the team. Documents and suggests, edits, processes and procedures to enhance claims submission accuracy and ensure claim technical requirements are met. 8.--Ensures patient/guarantor receives accurate, appropriate, statements through updating of related legacy system demographics and documentation. 9.--Communicates with patients, guarantors, payers, physician offices, and related internal departments as necessary, verbally and in writing, regarding any additional information needed, claim processing, claim or account status and balance due. 10.--Analyzes outstanding accounts and takes appropriate action to secure prompt and accurate payment of all claims submitted. Resolves issues preventing, reducing, or delaying payment through verbal and written with patient/guarantor, payer, physician offices, and related internal departments. 11.--Manages and maintains unpaid account inventory at minimum level through analysis, identification, and resolution, of all issues delaying payment through systemic or staffing changes based on work files and reports. Reports on issues and trends to Supervisor. 12.--Reviews and approves account adjustments and legacy system documentation as appropriate. 13.--Reports adjustment information as required or requested by Supervisor. 14.--Monitors, investigates, documents and reports trends and characteristics of claim processing delays, errors and denials with recommendations for resolution. 15.--Ensures all claims and follow-up activities comply with federal, state, and payer specific claim submission guidelines based on user specific reports and measures. Identifies, documents and refers issues of concern to Supervisor. 16.--Maintains current knowledge of all organizational compliance polices and procedures. Assimilates compliance standards into all facets of work. 17.--Maintains confidentiality of all patient, department, hospital and organization related information. Secures documents and other information in order to preserve the confidentiality of all Private Health Information. 18.--Receives, reviews, and promptly resolves and responds to written and verbal inquiries and requests related to patient accounts, account processing, and outstanding balances. 19.--Analyzes and triages through review, status of accounts and coordinates all other appropriate actions, such as securing expected payment, requesting appeals, resolving other claim processing issues, arranging patient payment plan, or need for financial assistance. 20.--Prepares documentation and provides other appropriate information to internal customers and external agents contracted by the organization to facilitate account resolution when team members need assistance. 21.--Serves as a resource in higher level complexity issues by: Researching, analyzing and responding to internal and external audits, and peer review organization inquiries. 22.--Provides analysis and documentation of system or process improvement initiatives in response to changing governmental, regulatory or payer requirements. 23.--Coordinates and responds to special focused projects and periodic governmental regulatory and payer specific reporting in a timely and accurate manner using multiple media. 24.--Participates in testing and implementation of new or upgraded, hardware, software and processes. Identifies, documents and recommends changes to system tables, parameters and masters, governing claims processing. 25.--Assists with Systems Support staff in training team on new materials as implemented. 26.--Supports claim submission and resolution for all payer groups, based on mastery of requirements. 27.--Performs other duties consistent with purpose of job as directed. JOB SPECIFICATIONS AND CORE COMPETENCIES Education: Work requires mathematical, analytical, communication and technical skills normally acquired through a high school level of education development with advanced mathematical or scientific curricula and two or more years specialized technical or post-secondary training or five or more years of related experience in acute care hospital claim submission requirements, with leadership responsibilities, plus up to three months of focused on-the-job training.-- Licensure: None Experience: Demonstrated knowledge of Health Insurance Privacy and Portability Act requirements, general claims processing components, advanced claim coding (Revenue, HCPCS, and CPT) and submission practices, as well as major payer processing requirements is necessary at a level usually attained in five to seven years related job experience with hospital claim submission, managed care contracting, or provider relations. Strong systems and electronic claim submission background necessary for successful integration into departmental operations. Strong competency with Personal Computers as well as intermediate level skills in Word Processing, Spreadsheet and E-mail applications required for performance and productivity assessments, data analysis, documentation, reporting and communications. Intermediate Internet experience to research claim issues and access payer websites also required. Must demonstrate the ability to assimilate experiences in responding to varied assignments. Must be able, and willing, to work under minimum supervision. Must possess a solid understanding of receivables management operations in a department that is complex and significantly automated. Other Job Requirements: Work volume is high, and must be prioritized in order to complete essential duties daily. Work involves superior math, communication, and analytical skills to independently reconcile accounts and resolve issues or discrepancies with outstanding balances. Must be able to interpret data in multiple systems in differing formats to problem-solve and provide options for solutions. Must be able to develop processes and present them to management for final approval. Work requires excellent judgment and negotiating skills to resolve issues related to payments, adjustments, and account balances and secure payment. Position requires reliance on experience and judgment to plan and accomplish assigned tasks and goals. Duties entail substantial variety and complexity in responding to changing environment. Periods of extreme mental concentration and pressure may be experienced because of the erratic nature of the workload. A significant level of initiative, self-direction and motivation is required to assure timely and accurate response to all issues. While supervision is available most times, the individual must be adequately proficient to work with little or no supervision, while seeking supervisory support appropriately. Primary communications involve patients, payers, third party administrators, business partners, agencies, and other departmental staff. Secondary communications involve other SJRMC personnel, and physician office personnel. Must possess skills to persuade payers to review global issues and bring them to resolution. Must demonstrate the ability to clearly articulate issues and information to a wide and diverse range of audiences. Must demonstrate excellent customer service and interpersonal skills, including verbal and written communication, judgment, and diplomacy. Assigned hours within your shift, starting time, or days of work are subject to change based on departmental and/or organizational needs. Note: Specific competencies relating to the units assigned and ages of patients served are separately maintained within each department.

Keywords: Saint Joseph Health System, South Bend , Claims Specialist - Centreal Billing Office - Full Time, Accounting, Auditing , South Bend, Indiana

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