Hospital Claims Specialist

4 days ago

Powder Springs, Georgia, United States Effingham Health System Full time
Job Summary

The Hospital Claims Analyst will perform accurate and timely filing of initial insurance claims and secondary claims, following up on claims not paid to ensure payment to the hospital and affiliated entities. This role requires strong communication skills, self-motivation, and the ability to work in a fast-paced environment.

Key Responsibilities
  1. Process and adjust inpatient and outpatient medical claims in a timely manner, adhering to departmental quality and production standards.
  2. Assist in researching and determining the status of medical claims to ensure billed dollars, claims aging, and pend values are consistent with contract provisions.
  3. Perform follow-up and take necessary actions to resolve errors and findings assessed by Internal Audit and performance improvement plans.
  4. Ensure the validity of claims by reviewing files and attached documentation for completeness and accuracy.
  5. Identify patterns in resubmitted and adjusted claims, and recommend solutions to the Director of Business Services.
  6. Document systemic root cause analysis and recommend solutions to the Director of Business Services.
  7. Resolve claims issues by researching claim situations and providing timely reports and responses.
  8. Enhance department productivity by recommending improvements to workflow processes and organizational structure.
  9. Ensure the completeness and accuracy of Standard Operating Procedures by providing feedback to the department director on procedures that require documentation or additional detail.
  10. Contribute to the team effort by accomplishing related goals and results as determined by the Insurance and Billing Department leadership team.
  11. Maintain documentation to support avoidance of negative financial, regulatory, and operational impact.
  12. Research and respond to inquiries from various departments.
  13. Provide detailed reporting on claims volume, billed charges, savings, etc.
  14. Increase subrogation recovery efforts on approved claims.
  15. Assist in gathering customer feedback, defining processes, and identifying best practices.
  16. Handle PHI and maintain member privacy in accordance with HIPAA standards at all levels.
  17. Exhibit proficiency in all realms of insurance billing, including managed care and commercial.
  18. Exhibit a thorough knowledge of hospital billing formats, specifically UB 04's, 1500's, and contract billing.
Requirements
  • Education level equivalent to completion of high school diploma.
  • Formal training in claims experience, including investigation, resolution, and operations.
  • Skill and experience in planning, organizing, implementing, facilitating, verbal and written communications.
  • Basic typing skills, ability to manage cash, and proper telephone etiquette.
  • Two years of billing/collection experience in the healthcare field.
  • Intermediate computer skills with Microsoft Office Suite (Word, PowerPoint, and Excel).

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