Insurance Follow Up Specialist 3 (Remote)

TITLE: Insurance Follow-up and Denials Specialist 3

REPORTS TO POSITION: Claims Supervisor or Director

DEPARTMENT: Single Billing Office (SBO)

OUR VISION: Creating America’s healthiest community, together

OUR MISSION: In the spirit of love and compassion, better health, better care, better value

DEPARTMENTAL SUMMARY: The Single Billing Office (SBO) at St. Charles Health System (SCHS) provides revenue cycle services to our multi-hospital and medical group organization focusing on billing, collecting, and posting revenue. The goal of the SBO is to deliver a delightful, transparent, and seamless experience to patients and customers that captures and collects the revenue earned by SCHS in a quality, efficient and timely manner. Services include but are not limited to: billing insurance claims, posting insurance and patient payments, resolving insurance denials, collecting unpaid insurance claims, maintaining payer contracts in the EMR, resolving under and over payments, identifying and resolving payer issues, processing refunds, processing financial assistance applications, billing patients, resolving patient accounts including patient questions, and vendor management: lockbox, clearinghouse, early out, collection agencies.

POSITION OVERVIEW: Insurance Follow-up and Denials Specialist 3 works complex insurance denials which require extensive understanding of payer reimbursement methodologies, billing and coding requirements, in depth research skills, coordinating with payers, and writing complex appeals. This position works with internal and external stakeholders including community providers, payer representatives, other SBO teams, and other St. Charles departments to resolve denials. Caregivers actively work to identify denial trends and possible solutions to resolve or mitigate these trends. This position assists other caregivers and is therefore required to understand all level one and two follow-up tasks.

ESSENTIAL DUTIES AND FUNCTIONS:

Able to work all payers, all denials, and all dollar amounts in all financial classes. Work may be sub-divided by dollar amount or denial type with a focus on higher dollar ranges (above $15,000) and complex denials (HB Inpatient (IP), payer specific IP billing requirements, IP bundling).

Identify and resolve complex denials through research, appeals, correcting and rebilling claims, locating and correcting coverage, submitting records, and escalating to payer and/or leadership.

Verify and update insurance coverage as applicable using EHR tools, payer websites, or via phone calls to payers.

Apply root case net adjustments when all collection options are exhausted.

Resolve claim edits within Medicare billing system (DDE).

Resolve complex payer and clearinghouse rejections (277’s).

Apply advanced research methodologies as outlined in the SBO department matrix.

Complex denials include but are not limited to (see matrix for complete list):

Apply intermediate knowledge of current reimbursement methodologies and billing requirements consistent with SBO complexity matrix.

Work to identify and resolve no response claims including but not limited to claims not received, unbilled claims, and unprocessed claims.

Locate missing payments and coordinate with Cash Management to obtain and post payment.

Submit corrected claims.

Process late charges using the late charge functionality,

Generate and release complex itemized statements and medical records.

Update claim information including ICN, authorizations, billing information, or other required claim elements.

Review and resolve Insurance Follow-up correspondence.

Enter clear and concise documentation in the EHR.

Mentor, train, and assist other caregivers.

Specialize in complex appeals, including assisting SBO caregivers, other departments, and patients with appeals.

Caregivers may work directly with IT or other departments to resolve issues requiring advanced operational expertise.

Identify payer issues and/or denial trends; work with SBO leadership to identify appropriate next steps including but not limited to system automations, payer contract opportunities, process changes, and department educational opportunities.

Maintain knowledge of current billing requirements and any changes via payer newsletters, payer workshops, payer webinars, or other applicable source.

Attend applicable meetings including payer meetings, clinical and support department meetings, and educational opportunities as appropriate.

Supports Lean principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.

Supports the vision, mission and values of the organization in all respects.

Provides and maintains a safe environment for caregivers, patients and guests.

Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.

Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient and accurate.

EDUCATION:

Required: High school diploma or GED.

Preferred: N/A

Required: N/A

Preferred: RHIT, Medical Coding or other applicable healthcare certification.

EXPERIENCE/SKILL SET:

Required: Seven years of applicable banking, finance, or related healthcare experience of which four years must have been in Insurance Follow Up or equivalent role. Three years of Epic experience.

Preferred: Experience using revenue cycle knowledge-based tools including applicable software and AMA manuals.

PERSONAL PROTECTIVE EQUIPMENT:

Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely.

ADDITIONAL POSITION INFORMATION:

Advanced knowledge of insurance billing requirements.

Advanced knowledge of payer reimbursement methodologies (must pass reimbursement knowledge skill test).

Strong communication skills, both verbal and written; demonstrated ability to write clear and concise appeals (must submit appeal sample).

Intermediate skills in Microsoft Office applications including Excel, One Note, Outlook, and Word.

Problem solving and research skills.

Process improvement experience/skills.

Public speaking experience.

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Schedule Weekly Hours:

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