Responsible for ensuring claims are resolved with third party payers in a reasonable time frame as defined by Revenue Cycle metrics. This includes working claims that fail payer rejection edits in order to resolve errors and submit corrected claims. Assesses errors and quickly and effectively locates information to correct them and follow-up on claims for resolution. Works with other areas in the Revenue Cycle to obtain information necessary to correct errors or supply additional information as necessary for claim adjudication. Remains up-to-date on regulatory requirements through informal and formal updates, including self-study of payer bulletins and guidelines. Performs other duties as assigned.

Essential Duties and Responsibilities

• Verifies claims are received by the payer and follows up to obtain payment via phone calls, portal or website use.
• Reviews claim adjustment reason codes or explanations of benefits received by the payer to determine what reasons for denials records are indicating for appropriate follow-up.
• After denial review, evaluates next steps and takes action to call payer, follows up with a resubmission or dispute/appeal/reconsideration as required by payer, or works internally to receive payment on account.
• Drafts an appeal or complete reconsideration forms when applicable based on payer requirements in a format that is logical and relates to the open denial of payment.
• Obtains and sends medical records during the appeals process when needed to substantiate medical necessity.
• Ability to review billing forms for both paper submissions and electronic submissions for accuracy.
• Calls patients or payers directly without hesitation to obtain needed information to resolve an account balance when applicable.
• Identify trends with payor rejections or denials and escalates these trends to leads/supervisors.
• Uses computer systems/technology to locate claims information to resolve account balances.
• Maintains compliance with patient financial services policies and procedures.
• Uses fax machine and other office equipment during the course of normal daily operations.
• Reviews accounts based on patient or departmental inquiries. Also, works and follows up with other Mercyhealth departments in a timely fashion if outstanding questions are not resolved and a claim is in jeopardy of not being paid.
• Interacts with other PFS staff members to provide pertinent information and to ask for guidance to resolve knowledge base deficiencies.
• Researches accounts at a higher level that are denied for No Authorization as a priority in the attempt to appeal or escalate to Precertification department if a retro authorization may be needed.
• Works billing functions when needed.
• Escalates high dollar accounts for a second level appeal if needed.
• Reports equipment malfunctions and supply needs, as necessary.
• Accesses available resources, such as the patient accounting system, biller files, other areas in the Revenue Cycle, or payer databases, to locate missing or incorrect information. Apply creative problem solving skills in order to overcome obstacles and resolve errors for claim adjudication.
• Coordinates with management and external departments to resolve unresolved accounts and potentially create process redesign initiatives for long term root cause resolution.
• Completes special projects as assigned.
• Maintains a comprehensive awareness of all insurance company updates including Federal and State guidelines.
• Meets productivity goals as assigned by the Revenue Cycle Director.

Education and Experience

High school diploma or equivalent.
Microsoft Excel required and healthcare billing experience preferred.
Undertakes self-development activities.
Basic understanding of working in multiple software applications at the same time.

Special Physical Demands

The Special Physical Demands are considered Essential Job Functions of the position with or without reasonable accommodations.
While performing the duties of this job, the employee is regularly required to talk or hear. The employee is most often required to sit; use hands to finger, handle, or feel and reach with hands and arms. The employee is occasionally required to stand; walk and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, depth perception and ability to adjust focus.

Mercyhealth offers a generous total rewards package to eligible employees including, but not limited to: 

· Comprehensive Benefits Package: Mercyhealth offers a retirement plan with competitive matching contribution, comprehensive medical, dental, and vision insurance options, life and disability coverage, access to flexible spending plans, and a variety of other discounted voluntary benefit options.

· Competitive Compensation: Mercyhealth offers market competitive rates of pay and participates in various shift differential and special pay incentive programs.

· Paid Time Off: Mercyhealth offers a generous paid time off plan, which increases with milestone anniversaries, to allow employees the opportunity for a great work-life balance.

· Career Advancement: Mercyhealth offers a number of educational assistance programs and career ladders to support employees in their educational journey and advancement within Mercyhealth.

· Employee Wellbeing: Mercyhealth has a focus on wellbeing for employees across the organization and offers a number of tools and resources, such as an employer-sponsored health risk assessment and a Wellbeing mobile application, to assist employees on their wellbeing journey.

· Additional Benefits: Mercyhealth employees have access to our internal and external employee assistance programs, employee-only discount packages, paid parental and caregiver leaves, on-demand pay, special payment programs for patient services, and financial education to help with retirement planning.