Under the direction of the Insurance Supervisor or Regional Business office Supervisor, the Insurance Team Representative is responsible for ensuring all services provided are billed accurately and timely in accordance with proper payor and regulatory requirements for paper and electronic claims submission. The Insurance staff is responsible for working all insurance denials; follow-up and claim edit work queues as well as paper correspondence to ensure accurate and timely reimbursement which requires on-going communication with clinical staff, patients and third party payors. The Insurance Team Representative will have knowledge of complex government and third party payor billing requirements, insurance terminology and CPT-4, ICD-9 and HCPC coding to facilitate accurate resolution of reimbursement issues.
1. Ensure payments from the various third party payors are received timely and accurately. Successful issue resolution will require an understanding of complex billing issues required by government agencies and third party payors.
2. Resolve internal billing issues via working claim edit work queues to enable proper claim submission to third party payors. Resolution will include editing incomplete claim information which entails knowledge of appropriate data required by payors for claim submission. Failure to complete accurately and timely will delay or prevent appropriate reimbursement.
3. Resolve issues with insurance companies via denial work queues to enable appropriate reimbursement and timely resolution of accounts receivables. Resolution may include working with payors and patients to resolve inappropriate denials and if not successful, initiate appeal process with payor. Determination of corrective action is then necessary to achieve final resolution.
4. Via follow-up account queues, determine reasons for non-payment from payors and initiate resolution through payor website or telephone calls that will result in adjudication of claim.
5. Resolve electronic payor rejections to enable correct submission of claims. Resolution may include sending letters to patients requesting coverage and subscriber information, updating electronic claim and Epic with the correct information.
6. Responsible for setting up Special Handling Accounts and coverage when appropriate due to carve out in patient benefit plan.
7. Review, investigate and resolve patient and third party correspondence on a timely basis. Resolution generally requires providing appropriate medical record information which includes verifying appropriate authorization has been received from patient and review of patient notes to remove any inappropriate PHI.
8. Review, investigate and resolve returned insurance claims on a timely basis. Resolution generally requires contacting patient to obtain corrected or missing information necessary for claim resubmission.
9. Recognize research and resolve any missing, misapplied or excessive discounts as determined by state and federal regulations and/or contractual agreements with third party payors. Resolution generally requires posting the missed discount in a zero pay batch in the Epic Payment Posting Module. Appropriate resolution will result in recovery of dollars not paid appropriately by the payors.
10. Perform account audits as needed to resolve outstanding balances.
11. Identify third party overpayments and initiate refund requests.
12. Research and resolve insurance related Epic In baskets from other departments.
13. Use knowledge and understanding of CPT-4, ICD-9 and HCPC'S coding to facilitate accurate resolution of reimbursement issues.
14. Apply undistributed insurance payments to accounts.
15. Perform charge transfers while maintaining accurate patient and guarantor information. This includes, but is not limited to reviewing charges, payments, adjustments and account notes.
16. Use knowledge of the DMG computer systems relevant to performing all job responsibilities.
17. As necessary, perform duties pertaining to Flex Optical Retail Payment posting.
18. Perform other duties as assigned.
1. High school diploma or equivalent.
2. Three (3) years of experience in a medical billing, insurance or financial setting with at least one year in medical billing.
3. Insurance claim filing or healthcare registration experience.
4. PC experience, 10-key, and typing skills.
5. Excellent communication and organizational skills.
1. Knowledge of insurance terminology.
2. Familiarity with CPT-4 and ICD-9 codes.
3. Epic Resolute or Prelude experience.
4. Knowledge of Microsoft word and Excel.
Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Ability to sit continuously for extended periods.
2. Ability to see fine print and use the computer for extended periods.
3. Ability to continuously perform fine motor tasks, such as computer, writing or phone tasks.
4. Ability to hear and converse on the phone and in person.
5. Ability to safely lift lightweight boxes and equipment weighing up to 20 pounds.
Dean Clinic –
Based in Madison, Wis., Dean Clinic consists of a network of more than 60 clinics in south-central Wisconsin. Our more than 500 physicians provide primary, specialty and tertiary care in the clinics as well as eye care through our Davis Duehr Dean locations. Dean Clinic also offers urgent care services and operates outpatient surgery centers. Dean Clinic joined SSM Health in 2013.
You’ve known us as many names throughout St. Louis, and now, we’re bringing our hospitals, doctors, home care and other services together under one name – SSM Health. With seven hospitals, 350+ physicians, more than 40 physician locations and 12,000 employees, we are part of something bigger and better. We’re connected to a wealth of resources, expertise and advance technology to help you, your fa...mily and our community live long, healthy lives.
We’ve grown and changed a lot over our 143-year history. Our name may be changing but our mission remains the same