Analyzes, investigates, and resolves claims/billing information and/or errors associated with inpatient and outpatient Commercial and Managed Care, Workers Compensation/Motor Vehicle Accident/Liability and Client Billing claims. Ensures compliance with key payor guidelines and Memorial Health organizational policies.  Embodies the Memorial Health System Performance Excellence Standards of Safety, Quality, Integrity and Stewardship that support our mission, vision and values.

1. Embodies the Memorial Health System Performance Excellence Standards of Safety, Quality, Integrity and Stewardship that support our mission, vision and values:

• SAFETY: Prevent Harm - I will put safety first in everything I do.  I will speak up, without fear, on matters of patient and colleague safety.  I will take action to create an environment of zero harm.

• QUALITY: Improve Outcomes -  I will continually advance my knowledge and skills.  I will seek out continuous improvement opportunities.  I will deliver evidence-based care that leads to excellence in outcomes.

• INTEGRITY: Show respect and Compassion  - I will respect others and show compassion.  I will behave honesty and ethically.  I will be accountable for my attitude, actions and health.

• STEWARDSHIP: Reduce Waste - I will use resources wisely and maintain financial stability.  I will work together to coordinate care and services across the health system.  I will promote healthier communities.

2. Processes inpatient or outpatient claims (or both) as assigned by management and as required by the varying business needs of the department. Resolves and investigates complex issues involving both types of claims and makes recommendations to management regarding trends, patterns, and procedures.

2. Utilizes Hospital Revenue Cycle Billing system, any additional Vendor systems used to support claims submission., and other key Payor websites to determine insurance eligibility and coverage for inpatient and outpatient Commercial/Managed Care/Workers Comp/MVA/Liability and Memorial Health Client Account claims.

3. Receives and examines daily listings (work queues) for assigned billing claims and determines which require further analysis and action.

4. Investigates assigned billing claims with incomplete/incorrect information and resolves problems or errors to ensure complete and compliant information accompanies the claim.

5. Prioritizes claims based on specified criteria and electronically files the claim, timeliness, accuracy, and processing procedures. At prescribed intervals, follows up for review to ensure smooth processing and timely delivery of monetary reimbursements.

6. Follows up and investigates unpaid items and other issues associated with unpaid claims. Contacts patients, guarantors, client accounts or other sources of third-party payment and secures arrangements for prompt payment.

7. Receives and researches claim denials, and as necessary, prepares or obtains the necessary documents to appeal the denial.

8. Reviews correspondence relating to Commercial/Managed Care/Work Comp/MVA/Liability and Client Account payments and claims; conducts the necessary research to provide supplementary background information regarding the inquiry.

9. Researches and resolves complex issues associated with Commercial/Managed Care/Work Comp/MVA/Liability and Client Accounts. As applicable, identifies, documents, and reports problematic trends to management.

10. Analyzes reports containing rejected account information and performs the necessary research to resolve the reason(s) for the rejection and secures any other required information.

11   Participates in the development of system edits designed to identify and ensure consistent and compliant data necessary for processing Commercial/Managed Care/Work Comp/MVA/ Liability and Client Account claims.

12. Responds to requests from internal departments regarding the proper coding, billing, and processing of Commercial/Manage Cared/Work Comp/MVA/Liability and Client Account claims.

13. Communicates and resolves issues with a variety of internal and external sources to resolve issues involving Commercial/Managed Care/MVA/Liability and Client Account claims. This may include internal departments, patients (or other responsible parties), third-party payors, social service agencies, PFS colleagues, other insurance carriers, service providers, community employers, and collection agencies.

14. Initiates corrections to charges and contractuals / allowances within scope of expertise and authority granted.

15. Identifies and calculates write-off amounts and secures the necessary approvals from management for processing.

16. Documents online systems and electronic files to ensure accurate data is noted regarding the status of claims and payments.

17. Ensures compliance to contract guidelines and facilitates accurate and timely reimbursements to the organization.

18. Provides technical assistance and cross-training to lesser experienced staff members as directed by manager or supervisor. May serve as a back-up for other areas within the unit or department, especially during times of special needs or staff absences.

19. Provides customer service review and ensures appropriate HIPAA authorization on file for legal related call center requests.

20. Corresponds with collection agencies regarding payments and other situations with accounts including: review and report of bad debt payments, and review and approval of suit authorizations.

21. Assists with PFS related Webmaster claim requests.

22. Performs other related work as required or requested.

The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job.  Incumbents may be requested to perform tasks other than those specifically presented in this description.