REIMBURSEMENT SPECIALIST

Claims Processor

Creates and processes claims / invoices associated with patient care services and equipment provided via Memorial Home Services of Central Illinois, Inc. Analyzes and resolves claims / billing information and / or errors associated with private pay, commercial or governmental insurance, and other third party carriers and collects outstanding balances due. Ensures compliance with Medicare / Medicaid guidelines and Memorial Home Services of Central Illinois, Inc. organizational policies.

Qualifications

Education equivalent to graduation from high school or GED is required.

Two or more years of insurance and / or health care billing experience is required. Previous experience with in the home medical equipment industry or as a collector is highly preferred.

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 governmental policies and company procedures is required.

Demonstrated 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, customer relations, and listening skills. Must demonstrate the ability to persuade and negotiate effectively.

Familiarity with medical terminology, medical procedural (CPT), diagnosis (ICD-9 CM) coding and HCPCS coding is highly preferred.

Responsibilities

• Receives and examines daily reports, for assigned billing transactions, and determines which require further analysis and action.
• Prioritizes billings and claims information and prepares the necessary paperwork, ensuring careful adherence to insurers' guidelines (where applicable), timeliness, accuracy, and processing procedures.
• Analyzes ECS (Electronic Claims Submissions) reports containing rejected account information and performs the necessary research to resolve the reason(s) for the rejection and secures any other required information.
• Investigates unpaid invoices, claim denials, and insurance correspondence to develop response or appeals to facilitate claim resolution. Contacts patients, guarantors, or other sources of third party payment as necessary to secure arrangements for payment.
• Researches and resolves complex issues associated with billing and collection of patient accounts. As applicable, identifies, documents, and reports problematic trends to management.
• Communicates and resolves claims issues with a variety of internal and external sources. 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.
• Communicates with patients, via phone or mail, to request information / documentation related to claim resolution, or to respond to patient inquiries or correspondence, or to facilitate payment of outstanding balances. Meets with customers in person as requested.
• Initiates adjustments to accounts receivables, including contractuals / allowances, within scope of expertise and authority granted. Log sheet is completed for any claim above permission levels, and supporting detail information and related documentation is attached and forwarded to the Reimbursement Manager for approval.
• Enters account notes in online systems and electronic files to ensure accurate documentation regarding the status of billings, claims, payments, collections activities, refunds and adjustments.
• Ensures compliance to Memorial Home Services of Central Illinois, Inc. policies, by identifying, initiating and processing accurate and timely refunds to private payers, commercial insurance, and / or governmental entities, any time an overpayment is identified.
• Responds to requests from internal departments regarding the proper coding, billing, and processing of claims.
• As directed and defined by management, orients and cross-trains on other unit duties that 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.
• Assists with training of new Reimbursement and Customer Service staff.
• Performs both Collections and Denial functions when necessary.
• Participates on work teams for Quality Improvement when necessary.
• Analyze receivable reports and follow-up on a timely basis the status of unpaid claims.
• Communicate professionally with hospitals, physician offices, co-workers and customers as appropriate.
• Monitor On-Hold aging claims to resolve issues / problems and facilitate timely release in accordance with department standards.
• Performs other related work as required or requested.