Job Description

This highly visible position is responsible for collecting, entering and submitting claim information, posting insurance payments and following up on unpaid, rejected and denied claims. This position will maintain accurate financial records and ensure effective payment procedures. Key responsibilities include reconciling claims runs, creating electronic claim files, resolving errors and identifying recurring billing errors and trends.

ROLE AND RESPONSIBILITIES:

• Enters information necessary for insurance claims such as patient, insurance ID, diagnosis and treatment codes and modifiers and provider information. Ensures claim information is complete and accurate.

• Submits insurance claims to clearinghouse or individual insurance companies electronically or via paper CMS-1500 form.

• Follows up with insurance company on unpaid or rejected claims. Resolves issues and re-submits claims.

• Works closely with insurance companies and provider representatives to get proper and timely payment and resolve billing issues.

• Communicate payment or denials that impact revenue to leadership.

• Review outstanding accounts and aging reports.

• May have to verify patient benefits eligibility and coverage.

• Collaborate with field staff to clarify diagnoses or obtain additional information needed for claims submission.

KEY PERFORMANCE INDICATIONS (KPIs):

• Monitor and improve the Daily Sales Outstanding (DSO) to ensure timely collections.

• Trace and reduce the Claim Denial Rate to increase the number of claims paid on the first submission.

• Maintain a low Claim Rejection Raate by ensuring accurate and complete claims submissions.

• Manage the percentage of AR Over 90 days to keep overdue accounts at a minimum.

• Aim for a high First-Pass Resolution Rate (FPRR) to maximize efficiency in the claims process.

• Ensure timely and effective follow-up on unpaid claims, measured by the AR Follow-Up Rate.

• Maintain and high Net Collection Rate to ensure effective collection of allowable charges.

• Track and report on other relevant KPIs to monitor performance of the billing and collections process.

REQUIRED EDUCATION AND EXPERIENCE:

• High School diploma or equivalent is required. Associates or medical billing degree preferred.

• 1-2 years of work experience in a similar job, or healthcare work environment, preferred.

• Knowledgeable on insurance and reimbursement process.

• Basic understanding of medical ICD 9 codes and CPT medical billing codes.

• Understands managed care authorizations and limits to coverage.

• Familiarity with HIPAA privacy requirements for patient information. Maintains and protects confidential information.

• Detail oriented and ability to prioritize work.

• Effective communication and follow-up skills.

• Good math and data entry skills.

• Experience with Sycle Practice Management Software a plus.

• Proficient in MS Office, use of computers and common office equipment.

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