Analyzes, investigates, and resolves claims/billing information and/or errors associated with the more complex inpatient/outpatient medical insurance claims. Ensures compliance with managed care guidelines and MMC organizational policies.  Embodies the Memorial Health System Performance Excellence Standards of Safety, Courtesy, Quality, and Efficiency that support our mission, vision and values.

1. Receives and examines daily listings for assigned billing claims and determines which require further analysis and action.

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

3. Prioritizes claims based on specified criteria and files the claim, either electronically or via paper claim. Ensures careful adherence to insurance guidelines, timeliness, accuracy, and processing procedures.

4. Researches and resolves complex issues associated with patient insurance accounts. As applicable, identifies, documents, and reports problematic trends to management.

5. Embodies the Memorial Health System Performance Excellence Standards of Safety, Courtesy, Quality, and Efficiency that support our mission, vision and values:

• SAFETY: Prevent Harm - I put safety first in everything I do.  I take action to ensure the safety of others.
• COURTESY: Serve Others - I treat others with dignity and respect.  I project a professional image and positive attitude.
• QUALITY: Improve Outcomes - I continually advance my knowledge, skills and performance.  I work with others to achieve superior results.
• EFFICIENCY: Reduce Waste - I use time and resources wisely.  I prevent defects and delays.

6. 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.

7. Provides input regarding system edits designed to identify and ensure consistent and compliant data necessary for processing medical insurance claims.

8. Responds to requests from internal departments regarding the proper coding, billing, and processing of medical insurance claims.

9. Communicates and resolves issues with a variety of internal and external sources regarding medical insurance claims. 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.

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

11. Identifies and researches the appropriateness of late charges and, as necessary, adjusts the charge / patient account based on research findings

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

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

14. Ensures compliance to managed care contract guidelines and processes at each work step to facilitate accurate and timely reimbursements to the organization.

15. May assist with special projects, analyses, or audits.

16. As directed and defined by management, orients and cross-trains on other unit duties which 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.

17. 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.