Position Summary:

Identifies and researches the basis for credit amounts due on the more complex patient health insurance claims. Initiates contractual adjustments on the account and/or processes refunds to patients, governmental agencies, or insurance companies.  Embodies the Memorial Health System Performance Excellence Standards of Safety, Courtesy, Quality, and Efficiency that support our mission, vision and values.

Education:

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

Experience:

Two or more years as a Billing Adjustment Specialist, or comparable insurance, accounting, and/or health care billing experience is required. Must possess the technical knowledge to process credit amounts due on routine and the more complex claims and resolve errors and complex issues associated with them.

Other Knowledge/Skills/Abilities:

• Demonstrates thorough knowledge of medical terminology, medical procedural (CPT) and diagnosis (ICD-9) coding, and hospital billing claim form UB-04.
• 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 multi-task while working on multiple responsibilities simultaneously.
• Demonstrated ability to work successfully with internal customers and external contacts is required.
• Possesses a highly developed critical thinking and problem solving-ability to work through complex situations.
• Demonstrates excellent oral and written communication, keyboarding, basic math, and problem solving skills.

Principal Duties & Responsbilities:

1. Identifies patient accounts with credit balances and prioritizes the daily reconciliation and processing of each account.

2. Analyzes credit balances on patient accounts and confirms the reason and validity of refunds or contractual adjustments prior to processing.

3. Approves and processes individual account refunds, contractual adjustments, or write-offs up to authority limit granted. Refers items above this level to supervisor or manager for approval prior to processing.

4. Identifies situations in which contractual adjustments are warranted by determining the original billed amounts as compared to the amounts allowed and prescribed by Medicare / Medicaid and/or managed care contracts, as applicable.
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. Uses an electronic spreadsheet to calculate contractual or credit adjustments and documents/posts these amounts to the appropriate account using system software.

7. Communicates orally and in writing with internal and external insurance representatives and/or governmental agencies (as applicable) to obtain insurance verification and to resolve account questions and billing issues.

8. Identifies errors or omissions and initiates corrections on accounts with credit balances.

9. Researches and reconciles unidentified payments and posts such payments to the appropriate account or initiates refunds as appropriate.

10. Researches and resolves payment issues associated with patient accounts. As applicable, identifies, documents, and reports problematic trends to management.

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

12. Responds to requests from internal departments regarding the billing, adjustments, and crediting of medical claims.

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

14. Ensures compliance to Medicare/Medicaid and/or 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.