Claims Specialist- FlexStaff

Performs various billing, collection and third party reimbursement functions.

Responsibilities:

• Reviews and investigates claims to be adjudicated by the TPA, including the application of contractual provisions in accordance with provider contracts and authorizations
• Compiles claim reports for adjustments resulting from external providers, vendors, and internal inquiries in a timely manner
• Investigates suspense conditions to determine if the system or procedural changes would enhance claim workflow
• Communicates and follows up with a variety of internal and external sources, including but not limited to providers, members, attorneys, regulatory agencies, and other carriers on any claim related matters
• Analyzes patient and medical information to identify COB, Worker's Compensation, No-Fault, and Subrogation conditions
• Validates DRG grouping and (re)pricing outcomes presented by the claims processing vendor
• Attends JOC meetings with providers as appropriate to assist in communicating proper billing procedures and to explain company coverage guidelines
• Assists TPA with provider compensation configuration by creating and testing compensation grids used for reimbursement and claims processing
• Ensures that refund checks are logged and processed, enabling expedited credit of monies returned
• Analyzes check return/refunds volumes and trends to determine root causes. Proposes workflow changes to correct and enhance claim processes to prevent returned checks/refunds
• Generates routine daily, monthly and quarterly reports used for managing process timeframes and vendor productivity, ensuring compliance with all regulatory requirements and contractual vendor SLAs

• Enters charges, payments, and adjustments into department computer system and/or posts to manual records. Reviews batches to ensure accuracy.
• Verifies patient demographics, third-party coverage, codes, allowances, etc.
• Prepares bills and/or correspondence to third-party carriers and/or patients for reimbursement for services rendered.
• Attends to telephone inquiries, audits and mail applicable to accounts receivable. Sets up financial agreements with patients, as required.
• Keeps billing files organized. Maintains daily, weekly and monthly records of fees collected.
• Performs related duties as required.

Qualifications:

• High School Diploma or equivalent, required.
• Bachelor's degree. Certified Professional Coder (a plus)
• Eight or more years of insurance experience within a healthcare or managed care setting (preferred)
• Prior third party insurance billing experience, required.
• Knowledge of medical terminology, preferred.
• Ability to communicate effectively.

*Additional Salary Detail

The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).

The salary range for this position is $28-$28/hour

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