Medical Claims Review Specialist I

OBJECTIVE:

To ensure that all charges, claims and/or vouchers have been accurately submitted to the appropriate payers in a timely manner and that complete and accurate payment is received from all payers and self-pay patients.

ESSENTIAL DUTIES AND RESPPONSIBILITIES:

• Review claims submissions for accuracy by confirming proper payer, authorizations, referrals and all other key billing components.
• Follow clams from submission to payment using EMR analytics, reports, payer portals and other resources as necessary
• Partner with third party billing company personnel to resolve billing issues and support the effort of submitting clean claims with any research in a timely and responsive manner
• Review payer EOBs for a complete understanding of payments and assignment to patient responsibility.
• Use your knowledge of health insurance claim processing, patient policies by payer and payer plan dynamics for commercial, governmental, worker's compensation, labor funds and others to assess accuracy of payments.
• Work diligently to resolve denied/rejected claims by researching and determining the causes of the unpaid claims and making every effort to resolve the denial/rejection in order to promptly resubmit to the payer.
• Respond to patient and/or insurer inquiries in a professional. timely efficient and knowledgeable fashion, ensuring HIPAA and MOC guidelines are followed. and /or refunds as necessary.
• Other job tasks as necessary

COMPETENCIES:

• Experience using EMR, EHR and other healthcare/billing related systems to include Allscripts, Mod Med, EPIC, Exscribe, Health Ipass etc., Experience with web portals such as Availity
• Proficiency using Microsoft Excel including advanced sorting, pivot tables and sum functions.
• Thorough knowledge of medical insurance terminology and payer explanation of benefits and experience working withmedical benefit plans department of labor for workers comp claims
• Experience with patient assistance and government programs such as Medicare and Medicaid
• Proficient at multitasking and managing competing priorities effectively.
• Effective written and oral communication.

EDUCATION AND EXPERIENCE REQUIRED:

• Minimum HS diploma, college degree desired but not required
• Four years direct experience with core competencies

WORKING CONDITIONS/PHYSICAL DEMANDS:

• Must be able to sit and work at a computer for extended periods of time
• Requires manual finger dexterity and vision corrected to normal range
• Must be able to lift 25 lbs