Claims Specialist

Summary:
The Claims Specialist is responsible for following up directly with commercial and governmental payers to resolve billing issues and secure appropriate reimbursement in a timely manner. This individual identifies and analyzes denials and payment variances and enacts corrective measures as needed to effectively communicate and resolve payer errors.

Job Duties & Responsibilities:

Examines denied and underpaid claims to determine reasons for discrepancies

Communicates directly with payers to follow up on outstanding claims, resolve payment variances, and achieve timely reimbursement

Works with management to identify, trend, and address root causes of denials; helps pinpoint strategies for reducing A/R

Maintains a thorough understanding of federal and state regulations, as well as specific payer requirements and explanations of benefits, to identify and report billing compliance issues and payer discrepancies

Effectively handles all communications, including telephone and email, from payers and departments with the business office

Participates in continuous quality improvement efforts on an ongoing basis, establishing goals with supervisors and tracking progress

Demonstrates initiative and resourcefulness by making recommendations and communicating trends and issues to management

Understand and maintains compliance with HIPAA guidelines when handling patient information

Performs other duties as assigned

Promote a team atmosphere by treating individuals with respect and honesty and by using direct communication and active listening skills.

• Be open to change and actively support change.
• Be open to others’ ideas and points of view.
• Evaluate employees objectively and provide employees with periodic feedback.

Promote department goals as well as the mission of the hospital.

• Communicate goals to fellow staff members.
• Maintain department policies and procedures.
• Include requirements and guidelines from external agencies (i.e., Joint Commission, State of Wisconsin).
• Maintain and/or communicate to appropriate party function backlog at a set time.
• Educate new staff regarding regulations or requirements of those functions that relate to their areas or departments, as directed.
• Demonstrate acceptance and training of student interns in the department, as directed.

Participate in hospital committees, performance improvement team meetings, and team projects, as directed.

• Demonstrate punctuality and preparedness.
• Demonstrate effective communication skills.
• Demonstrate good organizational skills.
• Contribute in a positive, solution-focused manner.

Conduct self in a professional manner.

• Demonstrate organizational skills that promote timely response to all inquiries and to task completion.
• Communicate with all individuals in a positive and professional manner.
• Attempt to resolve individual issues with peers in a positive, calm manner, with a focus on solution.
• Communicate concerns and provide solutions for same.
• Project a professional image by wearing appropriate, professional attire.
• Ability to influence departments within Rogers and provide technical guidance.

Additional Job Description:

Physical/Mental Demands:

• This role primarily involves sedentary work, requiring the employee to sit for extended periods. Occasional walking, standing, or reaching may be necessary to retrieve materials or operate office equipment. Lifting is moderate; must be capable of lifting a minimum of twenty (20) pounds. Reaching, handling, grasping and manual dexterity are necessary to operate various equipment.
• Verbal and hearing ability are required to interact with staff, consultants, patients and family members of patients. Numerical ability is required to maintain records and operate a computer.
• Tact is required to interact effectively with employees and professional staff. Logical thinking and discretion required to make decisions in initiating and implementing policies and procedures and standards.
• Must be able to read and communicate through written, verbal and auditory skills and abilities.
• Must be physically/mentally able to perform job duties as verified by a physical exam by a licensed physician, per post-employment physical.

Education/Training Requirements:

• High school diploma or equivalent required
• Minimum of one year of relevant experience in mental health or medical insurance billing and/or collections required
• Demonstrated knowledge of and experience with third-party payer guidelines, reimbursement, follow-up, and collections
• Demonstrated knowledge of claims review and analysis; ICD-10, CPT, and HCPCS coding; and medical terminology
• Effective communication, leadership, organizational, and problem-solving skills
• Ability to manage multiple tasks and projects simultaneously
• Ability to analyze data, identify improvement, and implement change
• Strong interpersonal and customer service skills
• Proficiency with Microsoft Word, Excel, Outlook, Teams, OneNote and Oracle Health Patient Accounting systems.
• Ability to work quickly and effectively in a fast-paced detail-oriented environment while adhering to deadlines.

With a career at Rogers, you can look forward to a Total Rewards package of benefits, including:

• Health, dental, and vision insurance coverage for you and your family 
• 401(k) retirement plan 
• Employee share program 
• Life/disability insurance 
• Flex spending accounts  
• Tuition reimbursement 
• Health and wellness program
• Employee assistance program (EAP)

Through UnitedHealthcare, UMR and HealthSCOPE Benefits creates and publishes the Machine-Readable Files on behalf of Rogers Behavioral Health.To link to the Machine-Readable Files, please visitTransparency in Coverage (uhc.com)