Company :Allegheny Health Network
Job Description :
Provides extensive support covering all aspects of insurance claims follow up, including direct contact to the appropriate third-party payers for all unpaid claims including denied claims and those requiring appeal. Manages all unpaid claims related inquiries. Trains and assists other team members as necessary.
- Ensures efficient processing of denials and appeals. Meets cash collection goals by reviewing, analyzing, completing, and submitting appropriate documentation based on payer requirements. Conducts research and provides updates and current status of collection efforts using the appropriate data management system (EPIC). Performs extensive follow-up to third parties, resolving issues that are adversely impacting claims payment. Communicates information and ideas to make system-wide process improvements. Updates data regarding changes and modifications in plan benefits and other contract information relevant to the claims follow up and collection process. (20%)
- Serves as a communication link to various departments and external payers by developing positive relationships with managed care organizations and outside agencies, and clinical areas within the organization. Performs liaison services to both internal and external customers providing assistance in claims resolution. Reviews and responds to correspondence and inquiries generated by third party payers. Provides medical record copies and other pertinent information to the appropriate sources throughout the collection process. Assists with education of internal staff and external customers to bring about the timely, accurate, and cost effective adjudication of all claims. Works collaboratively with other departments to facilitate the insurance collections process and to improve overall cash collection. (15%)
- Communicates team barriers, process flow or productivity issues to the supervisor. Assists team members in operational support and training. Assists in resolving claim issues requiring additional oversight by tracking and trending information and conducting root cause analysis. (15%)
- Monitors the status of denials, appeals, and claim errors by using work queues and conducting routine, periodic follow up on previously researched claims items. Monitors, reviews, and suggests revisions or updates to existing forms, documents, and processes required to secure timely payment. (15%)
- Ensures completeness of claims by following national, local, and internal billing requirements promoting prompt and accurate submission and payment. Maintains awareness of current regulations. Initiates practices that support current regulations. Shares knowledge of current regulations with staff. Analyzes current practices and makes recommendations for process improvements. (15%)
- Assists other departments/functional areas as needed with billing, claims, or claims follow up related tasks. (10%)
- Participates in committees as a representative for the department's interests, objectives, and/or goals. (5%)
- Performs other duties as assigned or required. (5%)
- 5 years in medical billing and collections
- Associate's Degree/Completion of college level coursework
- Previous experience working with third party payers
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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