What are the responsibilities and job description for the Temporary Insurance Follow-up Specialist position at St. Charles Health System?
The Insurance Follow-up and Denials Specialist 1 position works simple to intermediate payer denials that require an entry level understanding of payer reimbursement methodologies, billing guidelines, and coding requirements. This position works with internal and external stakeholders including community providers, payer representatives, other SBO teams, and other St. Charles departments to resolve denials.
This position does not directly supervise caregivers.
Essential Duties And Functions
Able to work all payers in a single financial class. Work may be sub-divided by dollar amount or denial type.
Identify and resolve denials through research, appeal, correcting and rebilling claims, correcting coverage, submitting records, and escalating to payer and/or leadership.
Apply root case net adjustments when all collection options are exhausted.
Verify and update insurance coverage as applicable using EHR tools, payer websites, or via phone calls to payers.
Apply entry to intermediate level research methodologies consistent with SBO department complexity matrix.
Denials include but are not limited to (see matrix for complete list):
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 patient health information system.
Identify payer plan issues and work with SBO leadership to identify appropriate next steps including but not limited to system automations, payer contract opportunities, process changes and educational opportunities.
Attend applicable meetings including payer 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.
May perform additional duties of similar complexity within the organization as required or assigned.
Education
Required: High school diploma or GED.
Preferred: Course work in medical terminology or other revenue cycle functions such as RHIT or medical coding. Course work in Microsoft Office applications.
Licensure/Certification/Registration
Required: N/A
Preferred: Certified Healthcare Financial Professional (CHFP), Certified Revenue Cycle Representative (CRCR), Certified Specialist Account and Finance (CSAF), Certified Specialist Payment and Reimbursement (CSPR), Registered Health Information Technician (RHIT), Certified Coding Specialist Physician Based (CCS-P), Certified Coding Associate (CCA), Certified Coding Specialist (CCS), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC), Certified Professional Coder (CPC), Certified Professional Biller (CPB).
Experience
Required: Two to three years of applicable banking, finance, or related healthcare experience.
Preferred: Prior experience in insurance follow-up working.
This position does not directly supervise caregivers.
Essential Duties And Functions
Able to work all payers in a single financial class. Work may be sub-divided by dollar amount or denial type.
Identify and resolve denials through research, appeal, correcting and rebilling claims, correcting coverage, submitting records, and escalating to payer and/or leadership.
Apply root case net adjustments when all collection options are exhausted.
Verify and update insurance coverage as applicable using EHR tools, payer websites, or via phone calls to payers.
Apply entry to intermediate level research methodologies consistent with SBO department complexity matrix.
Denials include but are not limited to (see matrix for complete list):
- Assistant surgeons
- Authorizations
- Benefit Maximum
- Simple billing requirements errors
- Bundled services (OP only)
- Simple charging related denials
- CLIA
- Simple coding related errors
- Coordination of Benefits
- Credentialing
- Duplicate denials,
- Inpatient Only Procedures (PB)
- Medical Necessity
- Medically Unlikely Edits
- National Correct Coding Initiatives (NCCI)
- Non-covered
- Payer specific billing requirements
- Record requests
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 patient health information system.
Identify payer plan issues and work with SBO leadership to identify appropriate next steps including but not limited to system automations, payer contract opportunities, process changes and educational opportunities.
Attend applicable meetings including payer 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.
May perform additional duties of similar complexity within the organization as required or assigned.
Education
Required: High school diploma or GED.
Preferred: Course work in medical terminology or other revenue cycle functions such as RHIT or medical coding. Course work in Microsoft Office applications.
Licensure/Certification/Registration
Required: N/A
Preferred: Certified Healthcare Financial Professional (CHFP), Certified Revenue Cycle Representative (CRCR), Certified Specialist Account and Finance (CSAF), Certified Specialist Payment and Reimbursement (CSPR), Registered Health Information Technician (RHIT), Certified Coding Specialist Physician Based (CCS-P), Certified Coding Associate (CCA), Certified Coding Specialist (CCS), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC), Certified Professional Coder (CPC), Certified Professional Biller (CPB).
Experience
Required: Two to three years of applicable banking, finance, or related healthcare experience.
Preferred: Prior experience in insurance follow-up working.