Claims Reimbursement Rep (BHS)

Reports to the Manager of Denials & Appeals. Performs a variety of duties related to Denial management efforts in coordination with multi-disciplines as assigned, by working collaboratively with all members of the Revenue cycle and clinical team to reduce third-party payer denials. The position holds the primary responsibility for following up on appealed claims, including collection efforts with third party payors, appeal processing, and reimbursement issues for Beacon Health System Reviews accounts and applies billing knowledge required for all insurance payors to insure maximum reimbursement is received. Investigate denial and appeal issues and past-due appealed insurance claims. Acts as a liaison with Managers, and insurance representatives to validate and correct information as well as consult with applicable BHS staff resources to optimize revenue performance. Actively follows up with insurance carriers for the purpose of collecting outstanding favorable appealed receivables.
MISSION, VALUES and SERVICE GOALS

• MISSION: We deliver outstanding care, inspire health, and connect with heart.
• VALUES: Trust. Respect. Integrity. Compassion.
• SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.

• Obtains and reviews Denials and Appeals reports, identifying accounts that meet criteria for follow up. Coordinate denial management process, focusing upon retrospective follow-up and appeal processing to appropriately maximize reimbursement based upon services delivered and ensure that the claim is paid/settled in the most timely manner possible.
• Appeal denied claims including writing and submitting appeals.
• Performing account follow-up with insurance companies to determine if the correct reimbursement has been received.
• Contact governmental and commercial payors to pursue collection efforts of favorable appealed claims

• Maintaining records, reports and files as required by established policies and procedures.
• Coordinates communication and follow up processes related to denials and appeals, ensuring that activities are tracked, trended, and reported to key stakeholders.
• Identifies solutions to issues affecting reimbursement as it relates to denial prevention (prospective and concurrent).
• Monitoring statistics related to appeal follow up and collection activities (for example, relative to established goals and budgets) and communicating with the Manager.
• Attending internal BHS meetings in order to occasionally serve as a technical resource to the Denials and Appeals Department.

• Act as a professional resource in regards to optimization of key revenue management, denials prevention, and billing compliance.
• Identify Root-Cause analysis as it relates to denials, appeals, and follow up activities.

• Providing excellent customer service at all times.
• Completing other job-related duties and projects as assigned.
• Attending in-services and department meetings; also participating in continuing education.
• Keeps abreast of all managed care and governmental payers billing requirements and guidelines.
• Reading current professional literature and journals.
• Attending billing/coding seminars when approved.

• Attends and participates in department meetings and is accountable for all information shared.
• Completes mandatory education, annual competencies and department specific education within established timeframes.
• Completes annual employee health requirements within established timeframes.
• Maintains license/certification, registration in good standing throughout fiscal year.
• Direct patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
• Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
• Adheres to regulatory agency requirements, survey process and compliance.
• Complies with established organization and department policies.
• Available to work overtime in addition to working additional or other shifts and schedules when required.

• The knowledge, skills and abilities as indicated below are normally acquired through the successful completion of a high school diploma or equivalent. Bachelor's Degree in related field preferred. A minimum of three years of experience in a medical/billing environment and previous collection experience is required. Knowledge of insurance and governmental programs, regulations, and billing processes, managed care contracts, and coordination of benefits is required. Working knowledge of medical terminology and medical record coding experience required.

• Demonstrates the interpersonal and communication skills (both verbal and written) necessary to deal effectively with a diverse group of people. Also must be able to discuss sensitive financial information in a tactful manner.
• Requires the analytical ability to review appealed accounts in order to determine the proper collection approach (according to established BHS policies/procedures) to be taken.
• Requires well-developed telephone skills. Also requires the basic math and accounting skills necessary to properly make calculations, balance records, prepare reports and apply computer concepts to billing practices.
• Requires the ability to compose written communications using correct spelling, grammar and format.
• Requires the ability to successfully negotiate payment plans and/or resolution of patient accounts in a professional manner.
• Requires extensive knowledge of DRG, CPT, HCPCS, ICD-10/ICD-9 coding, LCD/NCD policies, and specific payor policies.
• Demonstrates proficiency in basic computer skills (i.e., data entry, word processing and spreadsheets). A basic understanding of database applications is desired.
• Demonstrates knowledge of and a commitment to Beacon Health System's mission and values and the organization's goal of providing exceptional patient

• Works in an office environment.

• Requires the physical ability and stamina to perform the essential functions of the position.