Senior Insurance Claims Specialist

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Responsible for managing patient account balances including accurate claim submission, compliance will all federal/state and third party billing regulations, timely follow-up, and assistance with denial management to ensure the financial viability of the WVU Medicine hospitals. Employs excellent customer service, oral and written communication skills to provide customer support and resolve issues that arise from customer inquiries. Serves as a resource for co-worker process questions and concerns. Supports the work of the department by completing reports and clerical duties as needed. Works with leadership and other team members to achieve best in class revenue cycle operations.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. High School Graduate or equivalent.

2. Certified Revenue Cycle Representative (CRCR) Certification through the Healthcare Financial Management Association (HFMA) OR Certified Revenue Cycle Specialist through the American Association of Healthcare Administrative Management (AAHAM) within 90 days of hire.

EXPERIENCE: 

1. Three (3) years medical billing/medical office experience.

PREFERRED QUALIFICATIONS:

EXPERIENCE:

1. Three (3) years medical billing/medical office experience, preferably related to claims billing and insurance follow-up.

 

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

 

1. Submits accurate and timely claims to third party payers.

2. Resolves claim edits and account errors prior to claim submission.

3. Adheres to appropriate procedures and timelines for follow-up with third party payers to ensure collections and to exceed department goals.

4. Gathers statistics, completes reports and performs other duties as scheduled or requested.

5. Organizes and executes daily tasks in appropriate priority to achieve optimal productivity, accountability and efficiency.

6. Complies with Notices of Privacy Practices and follows all HIPAA regulations pertaining to PHI and claim submission/follow-up.

7. Contacts third party payers to resolve unpaid claims.

8. Utilizes payer portals and payer websites to verify claim status and conduct account follow-up.

9. Assists Patient Access and Care Management with denials investigation and resolution.

10. Accesses and utilizes all necessary computer software, applications and equipment to perform job role.

11. Participates in educational programs to meet mandatory requirements and identified needs with regard to job and personal growth.

12. Attends department meetings, teleconferences and webcasts as necessary.

13. Researches and processes mail returns and claims rejected by the payer.

14. Reconciles billing account transactions to ensure accurate account information according to established procedures.

15. Processes billing and follow-up transactions in an accurate and timely manner.

16. Develops and maintains working knowledge of all federal, state and local regulations pertaining to hospital billing.

17. Monitors accounts to facilitate timely follow-up and payment to maximize cash receipts.

18. Maintains work queue volumes and productivity within established guidelines.

19. Provides excellent customer service to patients, visitors and employees.

20. Participates in performance improvement initiatives as requested.

21. Works with supervisor and manager to develop and exceed annual goals.

22. Maintains confidentiality according to policy when interacting with patients, physicians, families, co-workers and the public regarding demographic/clinical/financial information.

23. Communicates problems hindering workflow to management in a timely manner.

24. Serves as a resource for co-worker process questions and concerns.

25. Works with Hospital Billing Trainer to identify training opportunities for staff.

26. Serves as a Super User for Quadax, FISS, and other PFS software applications.

27. Exceeds productivity measures in like work group as demonstrated by Epic dashboards.

28. Assists in the annual review of departmental policies and procedures and provides feedback.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

1. Must be able to sit for extended periods of time.

2. Must have reading and comprehension ability.

4. Visual acuity must be within normal range.

5. Must be able to communicate effectively.

6. Must have manual dexterity to operate keyboards, fax machines, telephones and other business equipment.

 

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

1. Office type environment.

SKILLS AND ABILITIES:

1.Excellent oral and written communication skills.

2. Working knowledge of computers.

3. Knowledge of medical terminology preferred.

4. Knowledge of third party payers required.

5. Knowledge of business math preferred.

6. Knowledge of ICD-10 and CPT coding processes preferred.

7. Excellent customer service and telephone etiquette.

8. Ability to use tact and diplomacy in dealing with others.

9. Maintains current knowledge of third party payer and managed care billing requirements and contracts.

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Day (United States of America)

Exempt/Non-Exempt:

United States of America (Non-Exempt)

Company:

SYSTEM West Virginia University Health System

Cost Center:

544 SYSTEM Patient Financial Services