The Claims Specialist is responsible for claims review, clearing claim edits, and timely and accurate submission of claims (both electronic and paper).
• High School Diploma or equivalency.
• 2 years experience in medical billing or registration.
• Experience in an academic healthcare environment preferred.
• None Required.
Knowledge, Skills & Abilities:
• Ability to understand and analyze system connections and impacts, both internal and external, for a large healthcare organization.
• Use relevant information and individual judgment to determine whether events or processes comply with laws, regulations, or standards.
• Knowledge of Coordination of Benefit Rules and correct filing order among various payers.
• Ability to complete detail-oriented work in a timely manner.
• Ability to maintain confidentiality and handle sensitive information with solid judgment and discretion.
• Ability to prioritize workload and meet quality and production standards.
• Ability to read and understand written sentences and paragraphs in work related documents.
• Ability to work well with a variety of people and be a team player.
• Excellent oral and written communication skills, with the ability to convey a positive and professional image, and to interact effectively with diverse personalities and backgrounds.
• Excellent typing/keyboarding skills with a high degree of accuracy to input data, process information and extract information in various report and presentation formats.
• Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar.
• Strong customer service and relationship management skills.
• Proficiency with Windows based software and Microsoft Office Suite products in a network environment.
Essential Duties and Responsibilities
• Review charges that may need to be routed to a different account type (VA, ACC, MVA), create new account types as needed, and add (or link) the correct coverage(s) to the new accounts.
• Review charges for any coverage errors and research available resources (EEV, payer websites, phone call to insurance) to determine correct information needed to clear the charge edit as appropriate.
• Resolve all pre-processing claim edits that indicate errors needing correction. This may involve updating patient registration information, posting rejections, or forwarding the claim to a medical coding specialist for review and coding changes prior to submitting the claim for payment.
• Continuously evaluate own work product to diagnose trends or patterns of errors needing corrections, and make recommendations to management regarding building in new edits, deactivating obsolete edits, or modifying existing edits to improve efficiency.
• Assimilate and operationalize all quarterly/yearly updates to each payer’s billing rules, guidelines, exceptions, and carve-outs, making sure we’ve captured any changes that may require building additional charge edits or claim edits.
• Prepare and submit pre-authorization questionnaires to Qualis or ProviderOne for any Health Care Authority claims requiring pre-authorization.
• Process all account merge requests in a timely manner when it’s determined there are duplicate patient accounts in our EPIC billing system.
• Review HMC Trauma Registry daily, flag all trauma-related accounts with UWPTRM patient notice, and follow up with Harborview staff to obtain ISS scores.
• Complete retro adjudication process using assigned work queues when new coverages are added to patient accounts by other areas, including reviewing for incorrect payments from insurance or patient, and rebill charges accordingly.
• Update or correct patient registration/demographics on accounts in the EPIC billing system.
• Update/edit charge entry detail for Medicare claims that have been corrected and need to be resubmitted electronically.
• Research and navigate a variety of databases to obtain/verify claim/eligibility information via payer websites and/or confer with payers by phone.
• Process claim attachments and secondary claims.
• Review and identify corrected claims to ensure that all necessary documentation is compiled for submission to payers.
• Answer questions regarding team functions.
• Conduct written and oral communications with insurance follow up teams/third party payers/others to resolve claims issues.
• Compile documents using correct filing order based on proper application of COB rules.
• Link coverage additions, deletions, corrections across all service areas in order to prevent future claim edits from firing.
• Perform other duties, as assigned.