UW Physicians -
Location
701 Fifth Ave, Ste 700
Seattle , WA , United States
98104
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Lead, Claims Specialist at UW Physicians

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Updated: Yesterday
The Lead Claims Specialist is responsible for developing more efficient and effective workflows for claims review, and clearing of claim edits. S/he identifies training opportunities, develops training materials (in conjunction with the UWP Trainers), and works directly with staff to ensure uniform application of all UW Medicine policies, procedures, and workflows. Additionally s/he performs Claims Specialist work in order to maintain queue volumes at a reasonable level, and in order to cover for scheduled absences and illnesses. Approximately 80% FTE will be spent in production, and 20% in analysis/training/development. The Lead will participate in on-the-job training thus s/he must possess superior claims management knowledge and skills, support learning and development opportunities for staff and effectively use one-on-one instructional techniques.
Education:
  • High School Diploma or equivalency.
 
Experience:
  • 3 years in medical billing (e.g. Claims Submission/ Payment Posting/ Collector/ Insurance Appeals).
  • Prior lead or training experience preferred.
  • Experience in an academic healthcare environment preferred.
 
Certification Requirements:
  • None required.
 
Knowledge, Skills & Abilities:
  • Resolve pre-processing errors and edits from payers. This may involve correcting patient registration information, posting rejections, or forwarding the claim to a medical coding specialist for review, prior to claims submission to payers.
  • Identify coding issues and provides coding feedback to the Pro-fee Coders as appropriate.
  • Effectively plan, organize, and work with the supervisor to schedule workload and manage production backlogs in an efficient and proactive manner.
  • Complete testing as needed by Applications Management regarding system upgrade, workflow changes and edit modifications.
  • 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, submitting necessary forms for system updates.
  • Monitor Account Merge requests in Service Desk Manager for volume and elevated priority situations.
  • Monitor & complete Visit Filing work queues when new coverages are added to patient account by other areas, including reviewing for incorrect payments from insurance or patient, and rebill charges accordingly.
  • Gather and maintain a base knowledge in all specialty workflows assigned to team members to be able to cover for absences, implications on system enhancements and trainings.
  • Make recommendations for the creation of new claim edits, deletion of obsolete ones, and/or revisions to existing edits in order to improve efficiency.
  • Keep current with payer updates and applies knowledge to assist in the adjudication of claims.
  • Work overtime as needed to meet deadlines and/or resolve backlogs.
  • Observe employees at work, provide feedback, and facilitate problem solving to enhance performance of team members: 
    • Address employee’s specific gaps in skill or experience through guidance and encouragement.
    • Introduce new procedures or technologies.
    • Help build strong workplace relationships and promotes a positive work environment through open and constructive communication.
    • Motivate, encourage and challenge staff.
    • Provide help and support when needed.
    • Work collaboratively with the training department to develop effective desk level support training.
    • Mentor and train staff to support achievement of quality assurance expectations.
  • Research and navigate a variety of sources to obtain/verify claim/eligibility information via payer websites and/or confer with payers by phone.
  • Answer questions regarding team functions.
  • Conduct written and oral communications with insurance follow up teams/third party payers/others to resolve claims issues.
  • Link coverage additions, deletions, corrections across all service areas in order to prevent future claim edits from firing.
  • Perform other duties, as assigned.
 
Computer/Software:
  • Proficiency with Windows based software and Microsoft Office Suite products in a network environment.

 

  • 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.
 
 
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