Medical Claims Specialist

6 days ago


Osceola, Wisconsin, United States Osceola Medical Center Full time
Job Summary

Osceola Medical Center is seeking a highly skilled Medical Billing Representative to join our team. As a Medical Billing Representative, you will play a critical role in ensuring the accuracy and efficiency of our medical billing processes.

Key Responsibilities
  • Investigate and resolve claim denials in a timely and professional manner.
  • Identify denial patterns and manage insurance project resubmissions with multiple claims.
  • Validate denial code/reasons following explanation of benefit (EOB) review and ensure coding is accurate and reflects the procedures billed.
  • Analyze all coding adjustments made on EOB to ascertain accuracy and valid support.
  • Review Summary Plan Descriptions and related insurance documents to ascertain benefits.
  • Determine and execute the best approach for denial resolution and processing appeal.
  • Ensure timeliness of all appeals according to Federal, State, and plan guidelines.
  • Generate appeals based on the dispute reason(s).
  • Document all actions taken during the appeal process and any follow-up required.
  • Request and obtain medical records, notes, and/or copy of claim as appropriate.
  • Resolve appeal claims with third-party payers.
Requirements
  • Familiarity with Medicaid and Medicare claims denials and appeals processing and regulatory requirements.
  • Knowledge and use of payer medical policy and Medicare LCD/NCD criteria.
  • Knowledge of billing and coding requirements.
  • Ability to effectively utilize Microsoft Office.
  • Excellent verbal, written, and interpersonal communication skills.
  • Ability to balance multiple demands and respond to time constraints.
  • High-level skills in organization, problem-solving, and analytical skills.
  • Capacity to manage time effectively, attention to details, and follow through.
  • Well-developed research skills.
  • Advanced technical skills to quickly learn hospital information systems.
  • Knowledge of contracting and credentialing implications on revenue cycle functions.


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