Contract Compliance Specialist

Collect Underpayment Reimbursement due for AAH Illinois hospitals and physicians from payers according to Federal/State/Local Regulations and contractual obligations.  Perform analysis of underpaid claims in order to determine appropriate course of action.  Identify and review documentation and specific account information to determine validity of underpayment.  Utilize payment variance workflow tools to initiate follow up and tracking.  Maintain strong knowledge of the requirements and contract obligations for all payers including current policies and procedures as related to payment variance management.  Document workflow tool with accurate, clear, and concise notes

Identifies, analyzes, and researches payment variance root causes and trends.  Assists in the development of corrective action plans for resolution of underpayments and insurance credit payment variances.  Investigates and generates reports to identify all accounts applicable to a particular trend and/or root cause. Collaborates with internal and external stakeholders to initiate corrective action plans to minimize preventable underpayments.  Monitor the progress and resolution of trends; evaluate the financial impact for the Revenue Cycle.  Identify and report new trends to management during weekly meetings.  Determine educational opportunities for underpayment trends with internal and external partners to improve processes for underpayment avoidance.  Identify insurance and patient refunds to refer to the Refund Team.

Education/Experience Required:

• Associate’s Degree or 3-5 years recent experience in hospital billing, hospital collections, payer contracting, or claims department within a health insurance setting.

• Plus at least 3 years claims processing/ adjudication experience including demonstrated success in utilizing problem solving and communication skills to diagnose problems and resolve complicated issues.

• Knowledge of third-party payer, Medicare/Medicaid guidelines

• Understanding of Medical terminology

• Experience in managed care contracts, reconciling patient accounts, and balancing payment transactions against contract rates and terms is strongly desired

• Ability to interpret contract terms is required •Knowledge of UB-04 requirements •Knowledge of CPT, HCPCs coding

Knowledge, Skills & Abilities Required:

• 35 wpm typing preferred

• Computer skills with strong Microsoft Office (Excel and Word), Outlook, Third Party Payer websites, and NEBO/Passport products including ECARE Online and ECARE Claims Management System.

• Ability to perform root cause analysis, problem solve, and prepare action plans for improvement initiatives.

Physical Requirements and Working Conditions:

• Extensive knowledge of payment, charging, and reimbursement methodology. • Ability to interpret clinical/payer policies and regulations.

• Ability to interpret and implement regulatory standards.

• Effective negotiating skills including the ability to resolve difficult claims issues.

• Able to identify the key parts of a contract and effectively support negotiations.

• Ability to manage projects and handle multiple priorities under stressful situations.

• Strong Analytical Skills

• Strong interpersonal, communication & persuasion/negotiation skills required to effectively interact with patients and third parties.

• Ability to listen to and understand information and ideas presented verbally and in writing.

• Consistently exercises critical thinking skills or use logic and reasoning to assess and resolve problems.

• Quickly makes sense of, combines and organizes information.

• Consistently maintains a professional and approachable demeanor.

• Effectively handles stressful and difficult situations, including but not limited to interacting with angry or unpleasant people, fielding complaints, settling disputes, resolving grievances and conflicts, and/or negotiating with others.

• Ability to work under pressure and meet stringent deadlines in a fast-paced environment.

• Ability to work independently

• Pays strong attention to details and maintains high degree of accuracy

• Successfully alternates between two or more activities or sources of information.

• Accepts responsibility and maintains high level of accountability •Strong collaboration skills

• Available to respond to patient/third party requests during scheduled shift.

• Ability to work on a computer for extended periods of time

• Ability to speak on phone throughout a daily assigned shift (with opportunity to alternate between sitting and standing if necessary).

• Ability to work effectively in an open floor environment