Responsible for investigating and resolving claim issues in regards to commercial and capitated IPA payors. Maximizes reimbursements through efficient, timely and comprehensive delinquent claim and denial management review. Complies with all contractual, state and federal requirements. Supports reconciliation of electronic claim files.
Primary Duties and Responsibilities
1. Consistently meets A/R aging goals for commercial payors.
2. Researches denials, identifies trends or coding errors. Facilitates coding reviews. Processes and/or appeals denials according to established Patient Account. Reports findings to supervisor.
3. Researches delinquent claims, identifies payor or claim office problems or trends, and reports findings to supervisor. Works with supervisor or payor to resolve issues.
4. Resolves patient, payor and other department staff inquiries according to established PFS protocols.
5. Researches overpayments, identifies root causes or trends, takes corrective action, and reports findings to supervisor.
6. Previous registration experience prefered.
7. Obtains medical records using established DuPage Medical Group guidelines for the order and return of medical records.
8. Performs accurate and timely reconciliation of electronic claim confirmation files. Identifies issues and reports findings to supervisor. Works with supervisor to resolve EDI issues.
9. Complies with adjustment and appeal procedures in conjunction with DMG Coding and Reimbursement guidelines.
10. Understands coverage and registration guidelines as they apply to commercial plans.
11. Understands coverage and registration guidelines as they apply to capitated IPA payors. Confirms eligibility, claim office address and member services phone number to insure accurate claim submission.
12. Understands contractual and referral requirements for capitated IPA payors/plans.
13. Interacts with other clinic, administration and Patient Account department staff to successfully reduce the A/R.
14. Participates in any rotation of unit responsibilities.
15. Attends available classes pertaining to position.
16. Responsible for maintaining accurate and current resource material. Utilizes material appropriately when making determinations for claim appeals.
17. Maintains department’s policies and procedure timeliness and accuracy standards.
18. Performs other projects and duties as related to organization’s objectives.
19. Maintains confidentiality of all information as stipulated in the HIPAA Privacy Rules and DMG confidentiality policy.
General Skills and Abilities Required
1. Effective in communicating verbally with other staff and departments related to commercial and capitated IPA claims and remittance.
2. Schedules and prioritizes for self. Establishes strategies to accomplish specific results and produces desired results.
3. Effective in identifying and analyzing problems. Generates alternatives and identifies possible solutions.
4. Fosters teamwork and positive rapport within all departments to maximize achievement of goals.
Special Skills or Licensure Requirements
1. Knowledge of ICD-9, CPT and HCPCS.
2. No licensure requirements.
Education and/or Training Required
High school graduate or one to two years related training. Data entry skills of 30 WPM required.
One to two years of related experience.
Typical Working Conditions
The work environment characteristics described here are representative of those an employee encounters while performing the essential function of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Typical Physical Demands
- Working with and around other people.
- High level of computer work.
- The noise level in the work environment is usually moderate.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Position in general is sedentary. Person must be able to move throughout and between facilities. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle or feel; and talk or hear. The employee frequently is required to reach with hands and arms. The employee is occasionally required to stand and walk. The employee must occasionally lift and/or move up to 10 pounds.
Dupage Medical Group - 4 years ago