Insurance Claims Resolution Specialist
3 weeks ago
At Virginia Mason Franciscan Health, we're dedicated to delivering exceptional patient care and exceptional patient experience. Our newly formed health system combines the expertise of 11 hospitals and over 5,000 physicians and providers, empowering us to make a greater impact on the health and well-being of our communities. As a full-time **Insurance Claims Resolution Specialist**, you'll play a vital role in addressing, resolving, and resubmitting outstanding insurance balances and routine denials. Your journey will take you through researching authorization and/or insurance eligibility, working with commercial and government health insurance payers, and resolving payment issues through investigation and evaluation of patient account information, medical records, claims, Explanation of Benefits (EOBs), reimbursement regulations, and communication with third-party payers. You'll remove barriers to processing claims by calling payers, working online systems, rebilling insurance via fax, electronic or hard copy, transferring payments, or adjusting accounts per FMG procedures. With attention to detail, you'll review insurance remittance documentation, research routine denial reasons, and gain experience in resolving issues through the appeal process. Your skills will be honed in working with a wide variety of CPT codes associated with multiple specialties, as well as broader knowledge of denial/reason codes and the ability to apply proactive critical thinking and troubleshooting skills to handle denials and resolution of issues that potentially impact revenue and customer satisfaction. You'll require some knowledge of insurance follow-up processes for government and non-government payers, insurance authorization/eligibility processes, privacy/confidentiality practices, medical terminology, and insurance payer requirements. A strong customer service mindset and ability to produce work with a high degree of accuracy/timeliness while meeting productivity standards are essential. Your responsibilities will include researching and resolving rejected, incorrectly paid, and/or denied claims within the established time frame; retrieving account data and referencing available resources to identify reasons for payment discrepancies and to quickly resolve outstanding claims in order to maximize appropriate revenue. You'll access work queues to review claim/account status and determine next steps/specific tasks to assure that accounts are properly reimbursed and to resolve payment issues. You'll understand and interpret insurance EOBs, knowing when and how to assure that maximum payment has been received; gain experience in accurately deciphering denial reasons and planning follow-up steps. You'll contact insurance companies, payers, and/or other stakeholders to gather all necessary information; resolve issues (within scope of position) and facilitate/expedite prompt payment of claims; reopen claims as necessary to facilitate maximum reimbursement from insurance companies. You'll communicate effectively over the phone and through written correspondence to explain why a balance is outstanding, denied, and/or underpaid using accurate and supported reasoning based on EOBs, reimbursement, and payer-specific requirements. You'll re-submit claims (in hardcopy or electronic format) as requested, including all appropriate information. You'll enter corrections in the practice management system to assure appropriate reimbursement is received for all FMG providers. You'll recognize when additional assistance is needed to resolve insurance balances and escalate appropriately and timely through defined communication and escalation channels. You'll resolve work queues according to the prescribed priority and/or per the direction of management and in accordance with policies, procedures, and other job aids. You'll organize open accounts by denial type or payer to quickly address in bulk with representatives over the phone, via spreadsheet, utilizing an online payer portal, etc. You'll document all activities and findings in accordance with established policies and procedures; assure the integrity of all account documentation; maintain confidentiality of medical records. You'll accurately document patient accounts of all actions taken in the billing system. You'll document clear and concise notes within Epic according to established standards to facilitate resolution of outstanding claims/issues and assure that other staff are able to understand the claim history. You'll meet quality assurance and productivity standards for timely and accurate denial resolution in accordance with organizational policies and procedures. You'll gain and maintain current knowledge of internal, industry, and government regulations as applicable to assigned function. You'll follow all department policies and procedures, desk-level procedures, guidance documents, or other work tools designed to ensure accuracy, especially those requiring use of appropriate payment or adjustment codes. You'll gain understanding of detailed billing requirements, denial reason codes, and insurance follow-up practices; gain advanced understanding of government and commercial insurance reimbursement terms, payment policies, and appropriate reimbursement amounts. You'll establish and maintain professional and effective relationships with peers and other stakeholders. You'll work collaboratively with payers and revenue cycle staff to explain denial or underpayment issues. You'll establish and maintain a professional relationship with clinics and FMG staff in order to research and/or resolve issues. You'll perform related duties as required. We offer a competitive salary range of $20.71 - $28.48 /hour, and we're an equal opportunity/affirmative action employer.
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