About the position
The Claim Resolution Specialist is responsible for all steps in resolving patient account balances with insurance payers. This process includes working online with payer websites for inquiries and telephone follow up with the payers to ensure proper reimbursement is received for provider services billed. The specialist will review medical records for appropriate documentation inclusive of correct CPT and payable ICD-10 codes before sending to payer, file necessary appeals or other miscellaneous steps to ensure payment.
Responsibilities
- Provides support services both on the telephone and in office as applicable for patients and authorized representatives regarding patient accounts.
- Follows up on all outstanding insurance claims at 60 days from the date of billing following established guidelines.
- Provides information pertaining to billing, coding, managed care networks, insurance carriers and reimbursement to providers, client staff and co-workers.
- Follows up on all returned claims, correspondence, denials, account reconciliations and rebills to achieve maximum reimbursement in a timely manner with emphasis on timely resolution.
- Recommends accounts for adjustments following department guidelines.
- Monitors reimbursement from managed care networks and insurance carriers to ensure reimbursement consistent with contact rates.
- Answers inquiries from client staff regarding billing issues.
- Uses payer web sites and eligibility portals to check claim status and to efficiently conduct accounts receivable follow up to maximize revenue.
- Adhere to all policies related to HIPAA and Medicare compliance.
- Performs other position related duties as assigned.
Requirements
- High School Diploma or equivalent required.
- Requires minimum of 3 years' accounts receivable experience and prior experience working in a medical billing office.
- Skills in computer programs, spreadsheets, payer applications and websites.
- Requires strong basic mathematical skills.
- Proficient with facets of the PM (Practice Management) system including patient registration, charge entry, insurance processing, advanced collections, reports and ledger inquiry.
- Requires and extensive working knowledge of managed care networks and insurance carriers.
- Requires and extensive knowledge of accounts receivable functions including CPT and ICD-10 coding.
- Excellent organizational skills and attention to detail.
- Strong analytical and problem-solving skills.
- Ability to understand and interpret policies and regulations.
- Ability to examine documents for accuracy and completeness.
- Ability to prioritize and multi task.
- Ability to communicate effectively and in a professional manner with others.
- Complies with HIPAA regulations for patient confidentiality.
