Job Specific Competencies Via electronic work lists, user generated reports or as directed by management, follows up on unresolved claims in a timely fashion. Includes claims with no response, pended or denied. Identifies rejected claims files, researches reject reason(s) and resolves affected claims errors. Resubmits files as needed to ensure receipt of clean claims. Assists system vendor with appeal requests, or processes appeals directly with payer for denied claims as dictated by department policy. When claims are denied for coding related reasons, effectively utilizes coding software and/or books to confirm coding accuracy in order to resolve claims with the payer. May seek assistance from clinic coders. Ensures claims have correct insurance information and are billed to insurances timely. Prepares and finalizes insurance claims for batch processing and submission to system vendor, clearinghouse or direct to payer. Ensures insurance coverage records are complete and accurate for patient accounts. Verifies insurance coverage via electronic means or by phone when required. Makes corrections as needed. Contacts patients or insured members to resolve insurance coverage discrepancies. Confirms receipt of batch claims by insurance, system vendor or clearinghouse via electronic means or by phone. Monitors files for acceptance by same as dictated by department policy (normally within 48 hours). Processes secondary and tertiary insurance claims, electronically or via paper, as dictated by department and payer policy. Receives and posts electronic or manual insurance payments and adjustments in a timely fashion. Resolves unidentified or problem payments according to department policy. Is sure to balance payments posted with remittance or EOB prior to completion. Receives, researches and processes insurance and patient correspondence. Processes adjustments and requests approval for write-off of balances as dictated by department policy. Is careful to use correct adjustment or payment codes for processing and reporting needs. Understands, utilizes and properly posts industry standard claims and remittance codes (CARC and RARC). Communicates with accounting department, via spreadsheets, regarding processed or pending payments for cash reconciliation purposes. Thoroughly researches insurance credit balances and processes adjustments or refunds as needed and dictated by department policy. Identifies trends in causes of credit balances as works with the appropriate CVCH departments (Patient Services, Billing, etc.) to prevent credit balances. Is responsible to remain current with general billing guidelines, reimbursement rules and regulations. For assigned payers, is responsible to remain current with their specific guidelines by reading payer publications and reviewing their websites. Understands FQHC billing nuances to ensure accurate coding and maximum reimbursement for related services. Attends conferences, seminars and webinars as requested to remain current on billing related policies. Maintains accurate, complete and auditable billing records in accordance with CVCH policy and procedures. Appropriately and thoroughly documents patient accounts and/or claims with each action taken and each contact made to resolve the claim or account balance. Scans appropriate documents for electronic storage purposes, according to department policy. Builds and maintains positive relationships with payers, clinical department staff, corporate compliance, etc. Participates with claims resolution meetings, projects or problem-solving processes for assigned payers. Utilizing approved methods, communicates incorrect application of insurance coverage or benefits with clinic department staff members. Meets with clinical departments as needed or requested to provide updates regarding insurance coverage or benefit application concerns. Participates with educational activities with clinical departments, corporate compliance, etc. to ensure lines of communication among departments remains open and positive. Assists providers, staff and insurance payer representatives with insurance and billing inquiries in a friendly and professional manner. Other responsibilities may include: Completes and follows up on credentialing and re-credentialing of providers with appropriate insurance companies. Provides information as needed for production reporting and to ensure job standards are consistently met or exceeded. Assists with internal audits by providing requested information and participating in review finding discussions regarding insurance processing performance. Submits to remedial training if substandard performance is identified through such audits. Assists co-workers and management with special projects related to claims or A/R clean-up efforts. To ensure uninterrupted service, participates in cross-training efforts and provides coverage for insurance processing and follow-up needs with non-assigned payers. Actively participates in departmental and/or organizational process improvement (lean) initiatives. Notifies management of audit requests by insurance payers and complies with requests in a timely manner. Performs other duties as assigned by management. Engages in training Patient Services and Call Center Agent’s to meet organizational needs. Performs complex holds to resolve denials and performs higher level tasks. General Duties and Responsibilities Performs other duties and tasks as assigned by supervisor. Expected to meet attendance standards and work the hours necessary to perform the essential functions of the job. Conforms to safety policies, general housekeeping practices. Demonstrates sound work ethics, flexible, and shows dedication to the position and the community. Demonstrates a positive attitude, is respectful, and possesses cultural awareness and sensitivity toward clients and co-workers. Keeps customer service and the mission of the organization in mind when interacting with all clients, co-workers, and others. Employees are expected to embrace, support and promote the core values of respect, integrity, trust, compassion and quality which align with the CVCH mission statement through their actions and interactions with all patients, staff, and others. Conforms to CVCH policies and Joint Commission and HIPAA regulations