Job Details

Claims Processing Specialist

Inspire health. Serve with compassion. Be the difference.

Job Summary

Provides accurate and timely submission of claims for Prisma Health to various payer sources based on timely filing guidelines. Ensures specialty accounts are followed up on in a timely manner with increased focus on aged and high dollar accounts. Follows up and pursues identified payer variances after comparing expected to actual reimbursement received. Responsible for working with other departments when issues arise such as missing payments, payer delays, and technical denials. Ensures payment amount(s) from insurance carriers are correct and posted to accounts. Reviews accounts after payment posting to determine if balance needs moved to secondary payer or patient liability. Knowledge of payers and provides support to other team members as needed. Demonstrates exceptional relationships with external payers and internal departments in accordance with Prisma Health Standards of Behavior and Compliance.

Accountabilities

• Works and processes the billing functions, including resolving the Discharged Not Final Billed/Stop Bill errors that prevented the account from billing, the resolution of Claim Edits in order to submit to our Claims Clearinghouse for electronic submission. Also processes the daily paper claims submissions for primary and secondary claims. - 30%
• Follows up on Specialty AR accounts assigned to determine if the claim has been accepted and processed for payment or denied. Reviews claim rejections and re-bills accounts when appropriate. Effectively and timely identifies the root cause of non-payment denials and works with the insurance company, the patient and Prisma Health departments to find resolution to claim denials, making all necessary claim and account corrections to ensure the full reimbursement of services rendered. - 25%
• Escalates accounts both at the payer and/or internally when appropriate, as well as involving the patient appropriately in accordance with the Prisma Health escalation guidelines in order to keep AR aging at acceptable levels for payer issues. - 10%
• Identify system issues through trending and repetitive actions that require workflow review or changes to resolve compliant billing. - 5%
• Utilize proper tools to communicate with Prisma Health department teams on specific errors for corrections related to their area of responsibility. - 5%
• Contacts insurance payers, patients or guarantors at established intervals to follow-up on status of delinquent accounts, determines the reason of delay and expedites payment. - 5%
• Must meet daily performance productivity and quality goals. Is attentive to detail and accuracy, is committed to excellence, looks for improvements continuously, monitors quality levels, finds root cause of quality problems and owns/acts on quality problems. Actively contributes to department goals. Effectively utilizes time and resources, assisting co-workers as time allows. Must be dependable. - 5%
• Maintains professional growth and development through seminars, workshops, in-service meetings, current literature and professional affiliations to keep abreast of latest trends in field of expertise. - 5%
• All policies and procedures will be strictly adhered to. HIPAA, security, dress code, etc. will be conscientiously followed. Understands, promotes and adheres to all matters of compliance with laws and regulations. High level demonstration of the Standards of Behaviors. - 5%
• Communicates well both verbally and in writing, shares information with others & has good listening skills. - 5%
• Performs other duties as assigned.

Supervisory/Management Responsibilities

• This is a non-management job that will report to a supervisor, manager, director or executive.

Minimum Requirements

• High School diploma or equivalent OR post-high school diploma/highest degree earned
• 3 years - hospital claims and billing follow-up; understanding of the hospital and physician claim forms, knowledge of payer guidelines.

In Lieu Of

• Bachelor's degree and 2 years of hospital billing, follow-up/denials.

Required Certifications, Registrations, Licenses

• CRCA or CRCR - preferred

Knowledge, Skills and Abilities

• Facility claims and billing follow up and/or medical office experience
• Communication skills and respect for details - preferred.

Work Shift

Day (United States of America)

Location

Patewood Outpt Ctr/Med Offices

Facility

7001 Corporate

Department

70019012 Patient Financial Services

Share your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.