Ambulatory Claim Editor

Summary

Ambulatory Claims Editor responsible for billing insurance companies and ensuring billing guidelines remain current. Operates a PC, phone, performs clerical duties, and other billing‑related tasks.

Patient Financial Services – Medical Office Building. Full Time, Daytime shift.

• Prepares and submits claims within the area of responsibility to third‑party insurance carriers electronically or by hard copy.
• Keeps updated on all third‑party billing requirements and changes for insurance types in the area of responsibility and communicates with PFS follow‑up and other billing staff.
• Secures needed medical documentation required or requested by third‑party insurers.
• Processes claim rejections related to billing errors or late charges/credits by resubmitting claims to third‑party insurance carriers.
• Works with HIM and auditing staff to ensure correct diagnosis/procedures are reported to third‑party insurance carriers.
• Monitors claims for missing information, authorization/control numbers.
• Completes work within authorized time to assure compliance with departmental standards.
• Verifies bridge routines are updated in EPremis and working properly.
• Corrects errors when a payer returns claims and re‑submits claims to the payer.
• Checks status of accounts on hold and determines whether to keep on hold or release daily.
• Sends applicable medical records and invoices as appropriate for the claim.
• Checks accounts for secondary insurance after primary payer has sent remittance and adjusts balances accordingly.
• Verifies claims are received by the payer.
• Ensures precerts, ABNs, and documentation is submitted as appropriate.
• Documents all activity in the computer to meet time filing limits.
• Keys all follow‑up activity into the computer on each account.
• Assists staff in the department on rules and regulations of the payers.
• Answers questions from patients or guarantors regarding insurance status.
• Researches patient accounts for information requested by management.
• Keeps abreast of pertinent federal, state regulations and laws, and TRHS policies as they presently exist and as they change or are modified.
• Understands and adheres to TRHS compliance standards, Corporate Compliance Policy, Code of Conduct, Conflict of Interest Policy, HIPAA, and TRHS privacy and security policies.
• Demonstrates the ability to perform tasks that meet age‑specific requirements of the persons, patients, vendors, and staff the employee interacts with.
• Offers suggestions to improve department operations and reduce costs.
• Attends mandatory education programs.
• Improves self‑knowledge by voluntarily attending continuing education/certification classes.
• Maintains required competency levels identified in written exams, skills checklists, labs, annual safety and health requirements, and service excellence education hours.
• Cross‑trains to better assist co‑workers and provide maximum efficiency in the department.
• Volunteers/participates on hospital committees, functions, and department projects.
• Manages resources effectively.
• Reports equipment needing repair to extend life and removes malfunctioning equipment out of service with timely reporting.
• Makes good use of time to avoid needless overtime.

• High School Diploma or Equivalent

Post‑high school courses in insurance billing, data processing, and medical terminology preferred. One (1) year of experience in billing of third‑party insurances for facility and professional services required.

Southwell/Tift Regional Health System, Inc. is an Equal Opportunity Employer.