Reimbursement Specialist

Description

Job Summary - Follow up on rejected claims and overdue insurance balances using Explanation of Benefits (EOBs) and other reports. Build and maintain relationships with payers. Not eligible for recruits located in Hawaii and California. 

Essential Duties and Responsibilities:

Rejected EOB

• Follow-up on denials on the Practice Management Dashboard within one (1) week that the rejected EOB is received.

Claim Denial

• Research and determined why a claim has been denied.
• If the claim is denied due to a coding error, notify the person that coded the services, so that they may correct the error.
• Supply the coder with all applicable information, including a copy of the denial.

Appeals

• Determine when an appeal, reopening, re-determination, etc. should be requested and the requirement of each insurance carrier.

Appeals Completion

• Complete the appeals, reopening, re-determination, etc. in it’s entirety and send all required documentation to the insurance carrier.

Carrier Calls

• Call insurance carriers to appeal payments that do not match contractual agreement.
• Notify supervisor of consistent contractual agreement discrepancies.

Patient Inquiries

• Respond appropriately and accurately to written and telephone inquiries from patients regarding their insurance questions and account balances.

Claims Work list

• Review and work the claims work list daily.

Un-applied Payments

• Review and work the un-applied payments and credit balances daily.

In-actives

• Use data from in-actives on the practice management dashboard, call payers or look up claim status on-line to inquire about unpaid insurance claims that are 45 days old; record response or activity in the computer.

Medical Record Requests

• Make necessary arrangements for medical records requests, completion of additional paperwork, etc.

Carrier Relationships

• Manage relationships with personnel from assigned carriers.

Manager Meetings

• Meet with manager regularly to discuss/resolve reimbursement and insurance follow-up problems.

Refund Requests

• Process requests for refunds and submit all required documentation to manager for approval.

Practice Management

• Working knowledge of practice management and word processing software.

Insurance Inquiries

• Respond appropriately and accurately to written and telephone inquiries from insurance companies.

Medical Billing Knowledge

• Knowledge of medical billing policies and procedures.

Insurance Provider Policy Knowledge

• Knowledge of insurance provider policies and procedures regarding patient claims.

Accounting Principles

• Knowledge of basic accounting principles.

Medical Terminology Knowledge

• Knowledge of medical terminology and basic human anatomy.

Interpersonal Skills:

Working Relationships

• Ability to establish and maintain effective working relationships with physicians, co-workers, and the public that harbor a friendly, yet professional interaction.
• Demonstrate willingness to readily interact with other staff members and department.

Mentor

• Acts as mentor for new employees.

Personal Growth

• Accepts responsibility for own professional growth and personal conduct by seeking knowledge in work specific areas, taking advantage of opportunities at work to observe and volunteer.

Flexibility & Stressful Situations

• Ability to be flexible, organized, and function under stressful situations.

Adherence to Facility/Departmental Policy:

Confidentiality

• Observe confidentiality of information in regards to patients, physicians, and fellow employees; ability to maintain confidentiality under HIPAA standards.

Attendance/Punctuality

• Maintain a good attendance record and arrive to work punctually.

Overtime

• Able to substantiate overtime, minimizes overtime and adjusts hours as needed.

Dress Code/Identification

• Follow dress code of department, appear professional when present in the clinic, wear identification while on duty, and communicate name and role to patient appropriately.

Cell Phone Use

• Cell phone may be used for business purposes only.
• Utilizes cell phone for personal use only during breaks or meal periods out of the public eye.

Staff Meetings/In-services

• Participates in Premier Bone & Joint Centers and departmental in-services and staff meetings.

Safety & Infection Control Policies

• Adhere to safety and infection control policies.

Care of Environment, Equipment, and Supplies:

Clean, Neat, Safe Environment

• Maintain a clean, neat, and safe environment for patients and staff, including personal work areas.

Office Equipment Skills/Malfunctioning Equipment

• Utilizing correct/safe technique when using equipment and notify manager of malfunctioning equipment.

Requirements

Education:

High School Diploma or Equivalent - Required

Experience:

Recent Clinical Experience in Healthcare Setting - Preferred

Physical Requirements

• Seeing - Must be able to read reports and use a computer - Constant
• Hearing - Must be able to hear well enough to communicate with patients, physicians administrative staff, insurance companies, and co-workers - Constant
• Speaking - Must be able to verbally communicate with patients, physicians, administrative staff, insurance companies, and co-workers - Constant
• Grasping - Must be able to write and type - Constant
• Standing - Rarely
• Sitting - Constant

Weight Demands:

• Lifting - Must be able to lift up to 10 pounds or less - Rarely

Working Conditions:

Environmental Hazards

• The fast paced environment may lead to increased levels of personal stress and demand high mental acuity.

Unique Work Schedule/Travel

• May be required to work after hours, on weekends, or holidays.

Employee Statement of Understanding

I have read and understand the job description for my position. I am able to perform all of the essential functions of this position.

I agree to comply with the corporate compliance policy and all laws, rules, regulations and standards of conduct related to my position. As an employee, I understand my duty to report any suspected violations of the law or the standards of conduct to my immediate supervisor.

As an employee, I will strive to uphold the mission and vision of the organization. All employees are required to adhere to the values in all their interactions with patients, customers, and fellow employees.

Note: This description is intended to describe the general job duties and employment requirements for adequate job performance, and should not be interpreted as an exhaustive report. Additional duties and responsibilities may be assigned at the discretion of the employees’ supervisor.