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Claims Follow Up Representative Job
Job Number: LCS17390
Job Title: Claims Follow Up Representative
Department: Third Party Follow-Up - 0014661
Facility: Corporate Headquarters
Location: Providence, RI
Equivalent to a high school graduate.
Knowledge of 3rd party billing to include ICD, CPT, HCPCS, UB and HCFA 1505 claim form.
Demonstrated skills in critical thinking, diplomacy and relationship-building.
Highly developed communication skills, successfully demonstrated in effectively working with a wide variety of people in both individual and team settings.
Demonstrated problem-solving and inductive reasoning skills which manifest themselves in creative solutions for operational inefficiencies.
One to three years of relevant experience in medical collections or professional/hospital billing preferred.
Incumbent generally establishes own work plan based on pre-determined priorities and standard procedures to ensure timely completion of assigned work. Problems needing clarification are reviewed with supervisor prior to taking action.
Under general supervision of the Claims Administration Follow-up Supervisor, performs all clerical duties necessary to properly process patient bills to customers taking appropriate follow-up steps to obtain timely reimbursement of each 3rd party claim and ensure the financial stability of the Hospital.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
Consistently applies the corporate values of respect, honesty and fairness and the constant pursuit of excellence in improving the health status of the people of the region through the provision of customer-friendly, geographically accessible and high-value services within the environment of a comprehensive integrated academic health system. Responsible for knowing and acting in accordance with the principles of the Lifespan Corporate Compliance Program and Code of Conduct. Review claim forms for all required data fields depending on the specific 3rd party requirements. Review patient account for demographic accuracy.
Processes all necessary system adjustments or changes as needed, such as adding/deleting insurance information, insurance priority changes, balance transfers, demographic changes, contractual allowances, and any other routine patient accounting adjustments not requiring supervisory approval ensuring accurate financial data.
Analyzes all assigned claims received from various sources to ensure accurate and timely reimbursement based on the individual payer’s contracts or Federal reimbursement methods. Contacts insurer via online systems, call centers, written correspondence, fax or appropriate electronic or paper billing of claims to secure payment.
Maintains an understanding of the most current contract language to consistently ensure reimbursement in accordance with contract language.
Continually maintains knowledge of payer specific updates via payer’s listservs, provider updates, webinars, meetings and websites.
Reviews payer’s settlements for correct reimbursement and proceeds with contact to insurer if claim is not adjudicated correctly based on working knowledge of the various payer’s policies and each individual related contract.
Identifies and analyzes denials and payment variances and enacts corrective measures as needed to effectively communicate and resolve payer errors.
Understands and maintains compliance with HIPAA guidelines when handling patient information
Initiates adjustments to payer’s as appropriate after analyzing under or over payments based on contract, Federal regulation, late charge corrections or inappropriate denials. Submits appeals to payers as appropriate to recover denied revenue
Contacts internal departments to acquire missing or erroneous information on a claim resulting in adjudication delays or denials.
Runs reports as necessary to quantify various variances on patient accounts related to identified issues within the payers or as the result of known charging errors or procedural breakdown.
Reports to supervisor identification of trends resulting in under/over payments, inappropriate denials or charging/billing discrepancies.
Answers telephone inquiries from 3rd parties and interdepartmental calls. Refers all unusual requests to supervisor.
Retrieves appropriate medical records documentation based on third party requests.
Initiates the accurate and timely processing of all secondary and tertiary claims as needed according to specific 3rd party regulations.
Processes all incoming mail and follow up on all rejections received according to specific 3rd party regulations.
Refers all accounts to supervisor for additional review if the account cannot be resolved according to normal patient accounting procedures.
Works with supervisor, management and the patient accounting staff to improve processes, increase accuracy, create efficiencies and achieve the overall goals of the department.
Maintains quality assurance, safety, environmental and infection control in accordance with established policies, procedures, and objectives of the system and affiliates.
Performs other related duties as required.