TITLE:                                      Insurance Follow-up and Denials Specialist 2

REPORTS TO POSITION:         Claims Supervisor

DEPARTMENT:                         Single Billing Office

OUR VISION:                Creating America’s healthiest community, together

OUR MISSION:             In the spirit of love and compassion, better health, better care, better value

OUR VALUES:              Accountability, Caring and Teamwork

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POSITION OVERVIEW: The Insurance Follow-up and Denials Specialist 2 works intermediate payer denials which require a higher-level understanding of payer reimbursement methodologies, billing, and coding requirements. Caregivers actively work to identify denial trends and possible solutions to resolve or mitigate these trends. This position must also be able to assist other caregivers and is therefore required to understand all level one follow-up tasks. This position works with internal and external stakeholders including community providers, payer representatives, other SBO teams, and other St. Charles departments to resolve denials.

ESSENTIAL DUTIES AND FUNCTIONS:

Able to work all payers and denials in a single financial class. Work may be sub-divided by dollar amount or denial type with a focus on intermediate dollar range ($5,000 to $15,000) and intermediate denials (HB OP and PB).

Identify and resolve intermediate denials through research, appeals, correcting and rebilling claims, locating and correcting coverage, submitting records, and escalating to payer and/or leadership.

Verify and update insurance coverage as applicable using EHR tools, payer websites, or via phone calls to payers. 

Apply root case net adjustments when all collection options are exhausted.

Resolve claim edits within Medicare billing system (DDE).

Resolve payer and clearinghouse rejections (277’s).

Apply intermediate to advance research methodologies consistent with SBO department complexity matrix.

Intermediate denials include but are not limited to (see department matrix for complete list):

• Intermediate billing requirements errors
• Intermediate charging related denials
• Intermediate coding related errors
• Inpatient Medical Necessity (Level of Service)
• Inpatient Notifications
• Inpatient Only Procedures (PB and HB)
• Inpatient length of stay authorizations
• Intermediate Medical Necessity

Apply intermediate knowledge of current reimbursement methodologies and billing requirements consistent with SBO complexity matrix.

Work to identify and resolve no response claims including but not limited to claims not received, unbilled claims, and unprocessed claims.

Locate missing payments and coordinate with Cash Management to obtain and post payment.

Submit corrected claims.

Process late charges using the late charge functionality,

Generate and release complex itemized statements and medical records.

Update claim information including ICN, authorizations, billing information, or other required claim elements.

Enter clear and concise documentation in the EHR.

Review and resolve insurance follow-up correspondence.

Distribute payments.

Assist SBO Customer Service and other departments in researching insurance related patient questions (emails or in-basket).

Identify payer issues and/or denial trends; work with SBO leadership to identify appropriate next steps including but not limited to system automations, payer contract opportunities, process changes, and department educational opportunities.

Maintain knowledge of current billing requirements and any changes via payer newsletters, payer workshops, payer webinars, or other applicable source.

Attend applicable meetings and trainings including payer meetings and educational opportunities as appropriate.

Supports Lean principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.

Supports the vision, mission and values of the organization in all respects.

Provides and maintains a safe environment for caregivers, patients and guests.

Conducts all activities with the highest standards of professionalism and confidentiality.  Complies with all applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.

Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient and accurate. 

EDUCATION:   

Required: High school diploma or GED.            

Preferred: Course work in medical terminology or other revenue cycle functions such as RHIT or medical coding. Course work in Microsoft Office applications.     

LICENSURE/CERTIFICATION/REGISTRATION:

Required: N/A 

EXPERIENCE/SKILL SET:

Required: Five years of applicable healthcare experience of which two years must have been in insurance follow up or equivalent role. Experience in an applicable financial, analytical, or medical billing and coding position may substitute for up to one of healthcare experience. One year of Epic experience.

PERSONAL PROTECTIVE EQUIPMENT:

Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely.

ADDITIONAL POSITION INFORMATION: 

Knowledge of standard insurance billing requirements.

Intermediate knowledge of payer reimbursement methodologies and appeal processes.

Basic to intermediate skills in Microsoft Office applications including Excel, One Note, Outlook, and Word.

Strong communication skills including ability to articulate complex technical issues impacting denials. Problem solving and research skills.           

PHYSICAL REQUIREMENTS:

Continually (75% or more): Use of clear and audible speaking voice and the ability to hear normal speech level.

Frequently (50%): Sitting, standing, walking, lifting 1-10 pounds, keyboard operation.

Occasionally (25%): Bending, climbing stairs, reaching overhead, carrying/pushing or pulling 1-10 pounds, grasping/squeezing.

Rarely (10%):  Stooping/kneeling/crouching, lifting, carrying, pushing or pulling 11-15 pounds, operation of a motor vehicle.

Never (0%):  Climbing ladder/step-stool, lifting/carrying/pushing or pulling 25-50 pounds, ability to hear whispered speech level.

Exposure to Elemental Factors

Never (0%):  Heat, cold, wet/slippery area, noise, dust, vibration, chemical solution, uneven surface.

Blood-Borne Pathogen (BBP) Exposure Category

No Risk for Exposure to BBP