Revenue Cycle Insurance Spec| Revenue Cycle Team - Anest​/OMFS Remote

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Responsible for obtaining appropriate reimbursement for Accounts Receivables for professional services of patients seen in physician offices, out‑patient hospital, in‑patient hospital, 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. Research charges to submit to appropriate carrier according to Federal/Managed Care rules, regulations and compliance guidelines.

Review codes using CPT, ICD‑10, HCPCS and CCI guidelines to ensure compliance with institutional compliance policies for coding and claim submission. Enter and bill professional charges into automated billing system program. Utilize resources and tools in the resolution of invoices following company policy for assigned payor(s). Resolve outstanding balances with internal and external communication with customers.

• Triage invoices, determine appropriate action and complete the process required to obtain reimbursement for all types of professional services by physicians and non‑physician providers while maintaining timely claims submissions and appeals processes.
• 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.
• Speak 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 on the status of work and unresolved issues; alert Team Leader of backlogs or issues requiring immediate attention.
• Identify trended denials and report to supervisor; export trended/unpaid invoices on Excel for tracking and provide to supervisor.
• Be knowledgeable of specialized billing such as contracts and grants.
• Perform special projects assigned by the Team Leader or Manager.
• Verify completeness of registration information; add and/or update as needed; verify and/or assign insurance plan and code appropriately; verify and enter patient demographic information utilizing 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 the needed information for claims resolution; this includes medical record requests, determining other health insurance coverage, authorization requirements, questionnaires, research of documentation and accounts, and communication with clinics for additional information.
• 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, conversations with insurance companies, clinics, etc., for all actions.
• Receive and make outbound calls, written or electronic communications; navigate multiple web portals and websites to insurance companies for status and resolution of outstanding claims, 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 work insurance denials; determine appropriate action needed. Interpret front‑end rejections;…