Position Summary
Ensure full reimbursement is received by the RRH for clinical services rendered including professional, long‑term/home care and hospital care, by effectively and accurately managing a receivable. Resolve edits to ensure accurate claims are sent to primary and secondary insurances. Research and resolve denials and payer requests for information promptly and accurately in order to secure payment. As a senior team member, create and document new processes and support denial analyses. Work as part of a dynamic team continually looking for ways to improve a complex business process.
Key Responsibilities
* Review and accurately process claim edits in a system workqueue. Accurately handle claim adjustments and coverage changes as needed.
* Review and process claim denials according to established processes. Research and resolve denial issues via the payer website, coverage policies and/or phone calls to the payer. Submit corrected claims and appeals.
* Process account adjustments and refunds as needed according to department policy and procedure.
* Document actions appropriately and follow‑up with payers to ensure they take actions promised. Follow‑up on claims with no responses. Manage large workload using tracking tools to ensure we don’t fail to follow‑up before a payer’s deadline.
* Help lead team meetings which review new procedures, new denial types and system updates. Report problems and patterns to the supervisor to help keep policies and procedures up to date with new clinical programs and payer policy changes. Answer staff questions about processes and problem resolution.
* Acquire and maintain knowledge of system terminology, claim/denial/coverage concepts and terms, and relevant HIPAA privacy rules and other regulations. Expertly use insurance websites to explore denial issues and resolve them using the tools in Epic, including accessing clinical documentation and authorization details.
* Respond to patient complaints by researching coverage and claim processing to ensure the patient responsibility is accurate. Contact insurance as needed. Coordinate resolution with Customer Service staff.
* Create and maintain documentation of billing processes to support audits and training. Support denial trend analyses and special projects.
* Work directly with outside departments to assure authorizations, medical records, and appeals are accurate and timely.
Desired Attributes
* i. 2 years work experience in a healthcare setting preferred
* ii. Proficient working knowledge of assigned receivable systems
* iii. General knowledge of Medicare, Medicaid and insurance compliance issues preferred
* iv. Familiarity with ICD-9 diagnosis and procedure codes as well as CPT/HCPCS codes helpful
* v. Knowledge of UBO4 billing form and 1500F05 specific payor requirements preferred
* vi. Proficiency in a variety of computer applications and spreadsheet applications and common office equipment
* vii. Excellent problem solving, organizational and oral and written communication skills required
* viii. Strong communication, analytical and PC skills highly desired
* ix. Excellent interpersonal, organizational, communication, attention to detail and follow through skills
* x. Flexibility and ability to work as a team player and to handle simultaneous tasks
* xi. Successful completion of annual age and job specific competencies and skill verification tools required
Minimum Qualifications
None
Required Licensure/Certification Skills
None
Rochester General Health System is an Equal Opportunity / Affirmative Action Employer. Minority/Female/Disability/Veteran.
PHYSICAL REQUIREMENTS
• Sedentary work – Exerting up to 10 pounds of force occasionally. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.
PAY RANGE
$19.00 – $22.50
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