Accounts Research Specialist - TMG Billing (Days)

Insurance Claims Specialist

Responsible for day to day follow-up of Medicare, Medicare Advantage plans, Medicaid, CMOs, and commercial insurance claims, and the review of aging reports to identify and resolve problem areas. Also includes the working of all rejections and denials accurately and efficiently. Necessary to prioritize work, formulate a plan of action, and analyze results, as well as communicate trends and billing coding issues.

Education

High School Diploma or GED

Experience

Two years of related experience. Requires working knowledge of specialized practices, equipment, and procedures.

Qualifications

*Ability to meticulously organize, analyze, and prioritize workload, and perform responsibilities with integrity. Ability to communicate issues to CBO management and offer a resolution.

*Ability to work professionally and closely with others, and function as a team member.

*Exhibit exceptional communication skills verbally and in writing.

*Minimum of two years experience in insurance and patient billing, and AR, which includes credits, refunds, offsets, and posting payments.

*Possess a comprehension of working and analyzing AR to resolve claim denials timely, and keep AR days, and greater than 90-day AR categories below MGMA standards.

*Working knowledge of CPT & ICD Coding, and medical terminology required.

Area of Responsibilities

*Analyzes and resubmits rejections, denials, and all levels of appeals for the purpose of identifying problems and recommending solutions to problems which cause delays in claim processing. Success will contribute to lower AR and improved cash flow.

*Provides comprehensive analysis and follow-up to all accounts of patients associated with Medicare, Medicare Advantage plans, Medicaid and CMOs, and commercial insurance - will include Worker's Compensation, Auto Insurance, Liability Insurance, and Supplemental Insurance in addition to primary commercial payers.

*Provides high quality services to all customers, which includes, but is not limited to, patients, physicians, physician practice employees, coworkers, and insurance companies. Performs responsibilities with professionalism and integrity.

*Sends written refund request to manager for approval. Completes the refund spreadsheet for Accounting, which the manager approves and forwards to Accounting for processing. Refund and supporting documentation are scanned and mailed to the insurance carrier, and copies are kept on file in the billing office. AR specialist follows the payer credit policy regarding offsets and refunds.

*Works accounts receivable according to CBO protocol and does not work denials prior to posting of the denials by the Cash Posters. Working AR results in meeting MGMA standards for AR Days and more than 90-day categories.

*Analyzes individual accounts and develops a follow-up, and collections strategy that results in payment in the shortest time possible.

*Analyzes work on hand on a daily basis and determines how to allocate manpower to achieve the greatest benefit. Determines when extra effort, and/or overtime, or weekend work is necessary. Approves all overtime and weekend work with director.

*Assists the payment processing team with posting checks at the end of the month.

*Assists with special projects and account analysis procedures when asked.

*Assures that payers are provided with necessary information and documentation immediately upon request.

*Develops and maintains a high level of expertise in the unique requirements of individual payer and Health West PHO managed plans.

*Develops and maintains a working knowledge of CPT and ICD coding.

*Develops and maintains an expertise level in Medicare and Medicaid plans regarding their rules, regulations, and policies by reading and studying all applicable bulletins, transmittal's, and manual revisions.

*Maintains a current knowledge of the TMG Billing and Collections procedures and the practice management systems. Maintains knowledge of rural and non-rural clinics. Maintains current knowledge of multi-specialty providers and settings.

*Maintains good relationships with physician practices for the purpose of resolving billing problems.

*Maintains strict confidentiality.

*Negotiates with insurance companies when refund requests are considered to be inappropriate or original reimbursement is questionable.

*Participates in educational activities and attends monthly staff meetings.

*Prepares monthly performance reports to indicate the impact of work done rather than the volume of work done. This will be done through analysis of aging reports, account receivable reports, and other related documentation.

*Provides customer service functions to include addressing patient inquiries, and complaints from all sources in a timely manner. Initiates necessary corrections to patients' accounts and attempts to repair any damage done to relationship with patient. This will require interaction with co-workers, physician's offices, and insurance carriers. Success indicated when problems are resolved by team members requiring little director intervention.

*Remains alert for process improvements and recommends changes when change would be beneficial.

*Remains up-to-date on insurance rules and regulations by subscribing to newsletters, attending seminars, and webinars.

*Responsible for determining whether commercial credit balances should be refunded to the insurance company. If more than one insurance company is involved, determine which should receive payment.

*Responsible for notifying CBO management of any payer changes that need to be updated with the Practice Management software.

*Works with all billing teams and the physician practices in making necessary corrections. Recommends process improvements which may reduce delayed payments.

Compliance Statement

Employee performs within the prescribed limits of Tanner Health System's Ethics and Compliance program. Is responsible to detect, observe, and report compliance variances to their immediate supervisor, the Compliance Officer, or the Hotline.

Education

High School Diploma or GED

Experience

Two years of related experience. Requires working knowledge of specialized practices, equipment, and procedures.

Licenses & Certifications

*NONE REQUIRED

Supervision

*Exercises no supervision.

Definitions

*Responsible for day to day follow-up of Medicare, Medicare Advantage plans, Medicaid, CMOs, and commercial insurance claims, and the review of aging reports to identify and resolve problem areas. Also includes the working of all rejections and denials accurately and efficiently. Necessary to prioritize work, formulate plan of action, and analyze results, as well as communicate trends and billing coding issues.

Contact With Others

Requires frequent contact with many persons at different levels inside and outside of the organization to carry out organization policies and programs and obtain willing acceptance, consent, or action.

Effect Of Error

Probable errors not easily detected and may adversely affect external as well as internal relationships and may result in major expenditures for equipment, materials, or procedures detrimental to the patient's welfare or the organization's interest. Work is subject to general review only and requires considerable accuracy and responsibility. Continually works with reports, records, plans, and programs of a major functional area of the organization where integrity is required to safeguard the organization's position. Duties may involve the preparation of data on which the administration bases important decisions and are highly confidential.

Supervisory Responsibility

Occasionally uses assistance of aide or helper in performance of task

Mental Demands

Work involves a variety of problems in a general field, some of which are complex. Involves some independent judgment to decide what to do to assemble facts, determine variations from standard procedures, or plan other action to be taken to meet general objectives.

Physical Effort

Minor physical effort - Job requires person to stand and/or walk frequently. Lifts, carries, or uses lightweight (1 to 25 lbs.) materials or equipment less than half of the day. Works in reaching or strained position intermittently. Office or laboratory work requires close visual effort less than half of day. Office or Laboratory work with concentration on a monotonous, repetitious procedure or skill most of day, where speed and accuracy are essential.

Working Conditions

Generally pleasant working conditions/normal office environment.

Physical Aspects

Continually (at least once per day)*Visual Frequently (at least 3 times a week)*Typing*Manual Dexterity -- pinching with fingers, etc.*Hearing*Speaking Occasionally (at least once a month)*Reaching -- above shoulder*Reaching -- below shoulder*Handling -- seizing, holding, grasping*Carrying