Insurance Claims Processor I

Summary of Essential Functions:

• Files insurance claims on the UB-04 and CMS 1500 form for hospital and physician services.
• Computes insurance benefits, allowances, adjustments, and patient balances.
• Processes, traces, and verifies reimbursement from payers, and other payers as assigned.
• Displays positive customer relations with other departments within the hospital, patients, and insurance companies.
• Work from home available after 60-90 days of on-the-job training.

Educational Requirements:

• High school graduate or equivalent.
• 1 to 2 years billing and/or claims follow-up obtained through related work experience or vocational school preferred.
• Insurance and medical terminology are helpful.
• Must be able to communicate effectively in English, both verbally and in writing.

Qualifications/Knowledge/Skills/Abilities:

• Knowledge in all areas of insurance, including but not limited, the ability to analyze and compile insurance billing data on the UB-04 and CMS 1500 forms.
• Knowledge of the filing practices for all third-party payers.
• Ability to compute insurance benefits, allowances, adjustments, and patient balances.
• Knowledge of the appeal process to government payers, and other payers as assigned.
• Ability to analyze payment practices of governmental payers, and other payers as assigned.
• Demonstrate diligence, patience, and persistence to obtain required information on outstanding accounts.
• Ability to read, comprehend and apply governmental rules and regulations.
• Ability to utilize tools available (i.e. payer websites).
• Knowledge of patient accounts and the ability to discuss account information with patients and insurance companies.
• Basic mathematical knowledge including understanding of debits and credits for correct account transactions.
• Type 45 w.p.m. ensuring correct spelling and grammar when documenting account actions or written communications.   
• Must have internet access and a secure office space to work from home.
• Requires the use of office equipment such as computer terminals, telephones and telephone headsets, copiers, 10-key adding machine, and fax machine.

Duties and Responsibilities:

• Compiles data and prepares insurance claims for billing utilizing patient, hospital and insurance data, and reviews LMRP queries to ensure proper processing.
• Reviews and corrects/posts appropriate adjustments to patient accounts. Investigates and corrects questionable charges to patient accounts.
• Processes and traces for hospital and physician claims ensuring timely filing to avoid missing deadlines.
• Utilize billing process to ensure claims are filed accurately daily. Properly applies the 24/72-hour regulations to ensure compliance.
• Verifies and calculates hospital and physician payments, follows up on incorrect payments or denials in a timely manner and ensures proper status of accounts.
• Generate appropriate secondary billing if applicable. Determine whether to re-file a claim, refund, or process an adjustment.
• Submit written and verbal inquiries to payers in an efficient and professional manner to determine status of claims.  Ensure accurate information is included for the payer to identify the claim.
• Supply payers with requested information for the claim to be processed in a timely manner. Document all information pending from other providers. Follow through on all resources by contacting other providers and inform them of pended claim due to their outstanding claim information. Contacts patients as needed for required information.
• Demonstrate diligence and persistence with payers while maintaining tact and diplomacy.
• Notifies management of any consistent discrepancies or potential reimbursement problems.
• Processes daily reports, mail, e-mails, and phone calls. All mail received is worked within 2 days of receipt and all information is documented in the patients account note file.
• Identifies Medicare and Medicaid combine messages daily. Responsible for obtaining proper assistance combining accounts.
• Non-billable report is worked daily ensuring adjustments are posted accurately and timely.
• Ensure all pertinent information is documented in the patient account note file. Ensure names and phone numbers are documented when applicable. Ensures correct insurance information is maintained and makes changes when necessary.
• Ensures work queues are reviewed and worked according to expectations.
• Maintains good working relationships with coworkers and revenue cycle departments.
• Maintains productivity set forth by department standards. 
• Performs all other tasks/responsibilities as necessary.