Revenue Cycle Insurance Specialist | Revenue Cycle - Team - Surgery REMO

Overview

Responsible for obtaining appropriate reimbursement for Accounts Receivables for professional services of patients seen in physician offices, outpatient hospitals, inpatient hospitals, ASC, urgent care, ER, off‑site hospitals, and telehealth locations while maintaining timely claims submissions. Registers patients and completes necessary documentation, including insurance verification and benefits determination. Researches charges to submit to the appropriate carrier according to federal and managed‑care rules, regulations, and compliance guidelines.

Reviews codes using CPT, ICD‑10, HCPCS and CCI guidelines to ensure compliance with institutional policies. Enters and bills professional charges into an automated billing system. Utilizes resources and tools to resolve invoices following company policy and resolves outstanding balances with internal and external communication with customers.

• Triage invoices and determine appropriate action to obtain reimbursement for all types of professional services by physicians and non‑physician providers, maintaining timely claims submissions and timely appeals processes as defined by individual payors.
• Resubmit insurance claims when necessary to the appropriate carrier based on each payor's specific process, with knowledge of timelines.
• Research, respond, and take necessary action to resolve inquiries from PSRs, Cash Department, Charge Review, and Refund Department requests; follow up via professional emails to ensure timely resolution of issues.
• Communicate with payors regarding procedure and diagnosis relationships, billing rules, payment variances, and assertively set expectations for review or change.
• Review, research, and facilitate the correction of insurance denials, charge posting, and payment posting errors.
• Follow all managed‑care guidelines using the UFJPI Payor Claims Matrix and Managed Care Matrix for each contracted plan.
• Identify and enter affected invoices on the MES (Monthly Escalation Spreadsheet) using Excel, ESM, or separate spreadsheets as needed.
• Inform Team Leader of the status of work and unresolved issues; alert Team Leader of backlogs or issues requiring immediate attention.
• Identify trended denials and report to supervisor, exporting trended/unpaid invoices on Excel to track and provide to supervisor.
• Be knowledgeable of specialized billing, contracts, and grants.
• Perform special projects assigned by the Team Leader or Manager.
• Verify completeness of registration information; verify and/or assign insurance plan and code appropriately; verify and enter patient demographic information using the automated billing system; verify insurance coverage using various online software tools.
• Work overtime as needed based on the needs of the business.
• Complete correspondence inquiries from payors, patients, and/or clinics to provide needed information for claims resolution, including medical record requests, determining other health insurance coverage, authorization requirements, questionnaires, and research of documentation and accounts. Communicate with clinics for additional information and collaborate with providers and other departments.
• Respond and send emails to all levels of management in the Revenue Cycle Departments, Cash Posting Department, Refunds Department, Managed Care, Referral Department, Clinics, and the CDQ Department to resolve coding and billing issues. Maintain timely communication to ensure all necessary action has been taken.
• Document notes in the automated billing system regarding patient inquiries and conversations with insurance companies and clinics.
• Receive and make outbound calls, written or electronic communications, navigate multiple web portals and websites to insurance companies to status and resolve outstanding claims.
• Process status appeals, reconsiderations, and denials.
• Make outbound calls to patients to obtain correct insurance information and demographics.
• Review and interpret electronic remits and EOBs to determine appropriate action for insurance denials.
• Interpret front‑end rejections, determine appropriate insurance adjustments, and obtain adjustment approvals as outlined in company policy.
• Verify and/or assign key data elements for charge entry such as location codes, provider #, authorization #, referring physician, CPT, ICD‑10, etc.

Experience

• 3 years of healthcare experience in medical billing preferred.

Requirements

• EPIC System experience preferred.
• Experience with online payor tools preferred.

Education

• High School Diploma or GED equivalent – required.
• Associate’s degree – preferred.
• Certification/Licensure Certificate – Medical Terminology – preferred.

Additional Duties:
Additional duties as assigned may vary.

UFJPI IS AN EQUAL OPPORTUNITY EMPLOYER AND DRUG FREE WORKPLACE