Claims Specialist

Rogers Memorial Hospital•Oconomowoc, WI

About The Position

The Claims Specialist follows up directly with commercial and governmental payers to resolve billing issues and secure appropriate reimbursement in a timely manner. The role examines denied and underpaid claims, identifies reasons for discrepancies, and takes corrective action to resolve payer errors. The specialist works with management to identify and address denial trends and root causes, helping reduce accounts receivable, while maintaining awareness of applicable regulations, payer requirements, and billing compliance issues. The position handles payer and business-office communications by telephone and email, participates in ongoing quality-improvement efforts, and communicates recommendations and trends to management. It also supports department operations through professional communication, adherence to policies and procedures, staff education as directed, participation in committees and projects as directed, and effective collaboration across departments. The role requires careful handling of patient information in accordance with HIPAA and the ability to work efficiently in a fast-paced, detail-oriented environment while meeting deadlines. The work is primarily sedentary, with extended periods of sitting and occasional walking, standing, or reaching. The employee must be able to lift at least 20 pounds and use office equipment. The role also requires communication, numerical, organizational, and analytical abilities, as well as tact and discretion when interacting with staff, patients, and others.

Requirements

High school diploma or equivalent.
At least one year of relevant experience in mental health or medical insurance billing and/or collections.
Demonstrated knowledge and experience with third-party payer guidelines, reimbursement, follow-up, and collections.
Knowledge of claims review and analysis, ICD-10, CPT, and HCPCS coding, and medical terminology.
Effective communication, leadership, organizational, and problem-solving skills.
Ability to manage multiple tasks and projects simultaneously.
Ability to analyze data, identify improvements, and implement change.
Strong interpersonal and customer-service skills.
Proficiency with Microsoft Word, Excel, Outlook, Teams, OneNote, and Oracle Health Patient Accounting systems.
Ability to work quickly and effectively in a fast-paced, detail-oriented environment while meeting deadlines.
Ability to sit for extended periods, with occasional walking, standing, or reaching; capable of lifting at least 20 pounds.
Ability to use office equipment and perform reaching, handling, grasping, and manual-dexterity tasks.
Verbal, hearing, reading, and written communication abilities to interact with staff, consultants, patients, and patients’ family members.
Numerical ability to maintain records and operate a computer.
Tact, logical thinking, and discretion in interactions and decision-making.
Physical and mental ability to perform job duties, verified by a post-employment physical examination by a licensed physician.

Responsibilities

Examine denied and underpaid claims to determine the reasons for discrepancies.
Contact commercial and governmental payers to follow up on outstanding claims, resolve payment variances, and obtain timely reimbursement.
Work with management to identify, trend, and address root causes of denials and strategies for reducing accounts receivable.
Use knowledge of regulations, payer requirements, and explanations of benefits to identify and report billing compliance issues and payer discrepancies.
Handle communications from payers and business-office departments by telephone and email.
Participate in ongoing quality-improvement efforts, establish goals with supervisors, and track progress.
Recommend actions and communicate trends and issues to management.
Maintain compliance with HIPAA guidelines when handling patient information.
Support a respectful, collaborative team environment and communicate professionally with coworkers and other individuals.
Maintain department policies and procedures, including applicable external agency requirements and guidelines.
Maintain or communicate functional backlog information to the appropriate party at the designated time.
Educate new staff on relevant regulations or functional requirements as directed.
Support and train student interns as directed.
Participate in hospital committees, performance-improvement meetings, and team projects as directed.
Provide technical guidance and influence departments within Rogers.
Complete other duties as assigned.