Position Summary:

Follows up on outstanding payments due on all types of open medical insurance claims, i.e., managed care and commercial. Coordinates activities with external insurance companies for the resolution of patient account balances. 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.

Education:

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

Experience:

Two or more years as an Account Follow-Up Specialist, or comparable years of medical insurance and/or health care billing experience is required. Possesses the technical knowledge to independently process claims of any denomination, type, and complexity is required.

Other Knowledge/Skills/Abilities:

• Demonstrates thorough knowledge of the electronic billing system, medical terminology, medical procedural (CPT) and diagnosis (ICD-9 CM) coding, DRGs and hospital billing claim form UB-04 is required.
• Demonstrates a thorough knowledge of contract management systems and Blue Cross and Tricare guidelines.
• 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 managed care contract policy provisions and company procedures.
• Demonstrated ability to work successfully with internal customers and external contacts is required.
• Possesses highly-developed prioritization and organization skills and critical thinking and problem solving ability.
• Demonstrates excellent communication skills, including telephone etiquette, and keyboarding and basic math skills.

Principal Duties & Responsibilitites:

1. Accesses external insurance providers’ websites to determine and/or verify patients’ insurance eligibility and account status.

2. Receives and examines daily listings for all denominations and types of patient accounts and determines which require further analysis and action.

3. Investigates assigned patient accounts with incomplete/incorrect information and resolves problems or errors to ensure complete and compliant information accompanies the claim.

4. Follows up and investigates all denominations and types of unpaid items and other issues associated with unpaid claims. Contacts patients, guarantors, or other sources of third party payment and secures arrangements for prompt payment.

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. Receives and researches insurance claim denials, rejections and underpayments, and as necessary, prepares the necessary paperwork to appeal the denial.

7. Reviews correspondence relating to payments and claims; conducts the necessary research to provide supplementary background information regarding the inquiry

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

9. 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.

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

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

12. Communicates and resolves issues with a variety of internal and external sources to resolves issues involving 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.

13. Initiates corrections to all denominations and types of charges and contractual/allowances within scope of expertise and authority granted.

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

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

16. Researches complex issues on all denominations and types of accounts and coordinates their resolution in a timely manner.

17. Ensures compliance to managed care contract guidelines and processes at each work step to facilitate accurate and timely reimbursements to the organization.
18. May assist with special projects, analyses, or audits.

19. 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.

20. Performs other related work as required or requested.