Document Service Representative

Overview

The Document Service Representative shall assume full responsibility for the completion of the activities related to processing incoming mail for the organization, and the timely and accurate facilitation and handling of all incoming paper claims and correspondence documents. All tasks are performed on-site. This includes performing a detailed mail sort, batch preparation, and scanning of all incoming claims and correspondence to facilitate and ensure compliance with applicable regulations and to ensure accurate image routing to the appropriate business area to support customer service levels.

Ownership is assumed for all aspects of claims examining and data entry on the Form Works system, utilizing and interpreting Desk Levels to accurately examine and data enter claims via OCR, Key from Image, and Key Entry. Required data elements as defined by each business area must be accurately captured in accordance with departmental Desk Levels, ensuring images are filed appropriately in Macess and work items are routed to the correct doc flo queue for handling by each business area.

The Document Service Representative will work closely with Member Services, Provider Services, Claims Operations, and Medical Affairs to resolve claims examining and correspondence data entry issues. The role requires applying problem solving and time management methodologies to balance multiple tasks as business needs arise while maintaining production and quality standards.

• Examine, data enter and re-write all physician, hospital, dental, and pharmacy claims utilizing established policies and procedures as well as medical claims coding guidelines.
• Perform accurate Form Works OCR error correction, Key from Image, and Key Entry on all medical, hospital, dental, and vision claims in accordance with departmental desk levels.
• Perform accurate Form Works data entry on correspondence documents in accordance with departmental desk levels to ensure work items are filed appropriately in Macess and routed to the correct doc flo queue.
• Report any scanning, data entry, or workflow issues to the Team Lead, Document Management and/or management as appropriate.
• Work mandatory overtime when deemed necessary to meet TAT service level metrics.
• Report any obvious provider billing problems observed.
• Provide value-added feedback regarding established desk levels and train newly hired staff when required.
• Maintain the production and accuracy ratio as established by the department.
• Direct claims and correspondence to the appropriate resource/department as needed in accordance with established Desk Levels.
• Research and contact appropriate resources as warranted for information necessary for the completion of examining and/or data entry utilizing the corporate documentation system.
• Initiate and assist in the development of process improvements necessary to resolve claims examining and data entry issues and system limitations.
• Perform all scanning room functions, including sorting, prepping, and scanning of all claims and correspondence documents into Form Works in accordance with established desk levels.
• Archive all incoming claim and correspondence documents in accordance with established Desk Levels.
• Complete the daily rejection report, including retrieval of archived claim and correspondence documents, within established time frames.
• Verify scanned documents for completeness.
• Report any system, filing, scanning, or workflow issues to the Team Lead, Document Management, and/or a member of management as appropriate.
• Perform general scanner maintenance as needed.
• Identify and report deviations in provider practice and billing to the Team Lead, Document Management.
• Complete required department documents in an accurate and timely fashion as outlined in established procedures.
• Comply with the company’s Corporate Compliance Policy and all laws, rules, regulations and standards of conduct, with a duty to report suspected violations to appropriate authorities and management.
• Performs other duties as assigned.

Education:

Please choose one (1) box highlighting the minimum educational level required to successfully perform the job. 1 High school diploma or GED required. 0 Associates degree or two (2) years of equivalent experience required. 0 Bachelor’s degree or four (4) years of equivalent experience required. 0 Advanced degree preferred.

Experience:

Six (6) months alphanumeric data entry experience in a healthcare setting is required;
Minimum of one (1) year claims examining procedural review experience utilizing CPT-4, HCPCS, and ICD-9 codes is highly preferred;
Experience with review, interpretation and scanning of correspondence from multiple sources is highly preferred;
Experience or working knowledge with an online data entry system, especially Macess EXP and Form Works, Web key is highly preferred;
At least one year of office experience with strong PC skills and Microsoft Windows is…