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DESCRIPTION
The AR Claims Representative is responsible for performing research and follow-up activities on assigned accounts in order to obtain additional reimbursement for Cloudmed’s clients.
RESPONSIBILITIES
- Ensure accurate and complete account follow-up by demonstrating a thorough understanding of carrier-specific reimbursement as applicable to claim processing to include: eligibility discrepancies, UB04 claims form preparation, DRG, per diem, case rate reimbursements, etc.
- Conduct appropriate activity on accounts by contacting government agencies, third-party payors, and patients/guarantors via phone, e-mail, or online. Continue reimbursement activity until account resolved
- Document all follow-up activity taken on an account in the patient account notes
- Resolve claim processing issues on a timely basis by reviewing claim inventories, payments, and adjustments daily
- Responsible for maintaining control of assigned inventory and ensure that daily productivity standards of accounts are met
- Taking appropriate actions to ensure payments and adjustments have been posted properly as well as identify applicable accounts for secondary billing and follow-up
- Research and document any correspondence received related to assigned accounts
- Assess accounts for balance accuracy, confirm correct payor billed, coding accuracy, denials, and outstanding insurance requests
- Provide documentation appropriately and submit corrections; or if payor error, escalate for re-processing in a professional and timely manner
- Request additional information from patients and payors as needed
- Review payor contracts to determine expected reimbursement from claims, identify underpayments, and draft payor demand letters
- Identify billing or coding issues and request re-bills, secondary billing, or corrected bills as needed
- Identify payor issues and trends, and escalate those issues to Management
- Ensure compliance with State and Federal Law Regulations for Managed Care and other Third-Party Payors
REQUIRED QUALIFICATIONS
- High School diploma required. Associate’s or bachelor’s degree preferred
- 2+ years of experience with medical claims and/or hospital claims experience
DESIRED QUALIFICATIONS
- Must be able to communicate effectively and professionally with strong attention to details and problem solving both verbally and written. Specifically, strong telephone communications skills are required
- Ability to prioritize work and meet deadlines is required
- Knowledge of general office procedures is required
- Ability to operate common computer systems, utilize hospital patient accounting system and business software is required
- Intermediate understanding of ICD-10, HCPCS/CPT coding, and medical terminology
- Strong proficiency in Microsoft Office (Word, Excel) skills
- Advanced business letter writing skills to include correct use of grammar and punctuation
- Understanding of the revenue cycle process
- Strong interpersonal skills
- Above average analytical and critical thinking skills
- Ability to make sound decisions
- Has a full understanding of hospital reimbursement, Intermediate knowledge of Managed Care contracts, Contract Language and Federal and State requirements.
- Familiar with terms such as HMO, PPO, IPA, capitation and how these payors process claims
- Intermediate understanding of EOB, hospital billing form requirements (UB04) and familiar with the HCFA 1500 forms
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