The Accounts Receivable Claims Specialist assures timely reimbursement of clean claims, corrects denied claims, and appeals denied or delayed claims with specific payors in order to receive reimbursement for healthcare claims. Responsible for aging management and efficient claims collections and (1 st Level) follow up.
Medical, paid holidays, paid sick days.
Essential Functions: Essential functions encompass the required tasks, duties and responsibilities performed as part of the job and the reason the job exists.
- Knowledge of payor guidelines.
- Knowledge of industry standard and Medi-Cal denials reasons/codes.
- Compiles billing, and payor documentation to create training documents.
- Ensures healthcare facilities are reimbursed at the correct rate for all procedures.
- Processes payments from insurance companies.
- Follows up on claim submissions to determine batch acceptance, rejection, or denial in a timely manner.
- Researches, corrects, resolves, resubmits and appeals denied claims/services.
- Corresponds with insurance companies to resolve the issue; submits appeals per payor requirements.
- Maintains collections rate for assigned payors at or above 70% of allowed charges.
- Maintains A/R percentage of 20% for A/R less than 90 days.
- Communicates with RCM leadership about payor updates, changes, and requirements.
- Reviews delinquent accounts and calls responsible party(ies) for collection purposes.
- Sorts and files paperwork from health plans, patient charts, and payment correspondence.
- Updates Division of Financial Risk (DOFR) quarterly with staff and report issues to supervisor.
- Supports team in their efforts to provide payors with information or documentation necessary for payment of claims and/or any other account follow up required to recover payment within a required timeframe.
- Reviews underpayments and overpayment trends and report to supervisor.
- Maintains refund log and enters refunds in system.
- Investigates insurance fraud and reports immediately if found.
- Maintains strict confidentiality at all times.
- Ensures timely filing of insurance claims
- Assists with processing incoming mail including payments and EOB statements.
- Prepares adjustments for patient accounts.
- Follows up on unpaid or underpaid claim charges (1 st Level).
- Maintains a log of open issues with dates for follow ups.
- Performs 1 st level collections on accounts with overdue balances.
- Responds to payor requests for information in a timely manner.
- Participates in payor meetings as needed.
- Manages AR reports to quantify, track and trend payor issues.
- Submits 1 st level appeals.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- High School Diploma or equivalent required.
Minimum Work Experience
- A minimum of 2-4 years of experience as a medical biller/claims follow-up specialist or collections specialist in an outpatient medical setting (non-hospital) in primary care (required), family planning, ob-gyn, and related surgeries required.
- Knowledge of medical terminology and common industry abbreviations required.
- 2-4 years of experience in billing and coding procedures required.
- 2-4 years of experience with insurance billing and reimbursement procedures required.
- A minimum of 2 years of experience with HIPAA 5010 transaction standards required.
- A minimum of 2 years of claims follow-up/appeals and health plan Accounts Receivable management for specific payors required.
- Ability to successfully communicate with payors including insurance companies, health plans, and medical groups regarding unpaid claims.
- Knowledge of Medi-Cal Managed Care, Commercial Payors, Medi-Cal, FPACT, & PE.
- Knowledge of health care and Medi-Cal denial reasons, denials codes and descriptions and standard denial resolution practices.
- Ablility to work flexible hours including weekends.
- Position Covers Business Administration, Business Operations, Client Relationship, SAP End To End Implementation, SAP Product Support
- Experience Required 2-plus-years
- Relocation Need To Relocate as per Requirements
- Notice Period Immediate To 30 Days