Strategic Medical Claims Specialist

Responsible for managing patient account balances, including accurate claim submission, compliance with all federal, state, and third‑party billing regulations, timely follow‑up, and assistance with denial management to ensure the financial viability of the WVU Medicine hospitals. Employ excellent customer service, oral and written communication skills to provide customer support and resolve issues that arise from customer inquiries. Supports the work of the department by completing reports and clerical duties as needed.

Works with leadership and other team members to achieve best‑in‑class revenue cycle operations.

• High School diploma or equivalent.

• One (1) year medical billing/medical office experience.

• Submit accurate and timely claims to third‑party payers.
• Resolve claim edits and account errors prior to claim submission.
• Adhere to appropriate procedures and timelines for follow‑up with third‑party payers to ensure collections and exceed department goals.
• Gather statistics, complete reports and perform other duties as scheduled or requested.
• Organize and execute daily tasks in appropriate priority to achieve optimal productivity, accountability and efficiency.
• Comply with Notices of Privacy Practices and follow all HIPAA regulations pertaining to PHI and claim submission/follow‑up.
• Contact third‑party payers to resolve unpaid claims.
• Utilize payer portals and payer websites to verify claim status and conduct account follow‑up.
• Assist Patient Access and Care Management with denial investigation and resolution.
• Participate in educational programs to meet mandatory requirements and identified needs for job and personal growth.
• Attend department meetings, teleconferences and webcasts as necessary.
• Research and process mail returns and claims rejected by the payer.
• Reconcile billing account transactions to ensure accurate account information according to established procedures.
• Process billing and follow‑up transactions in an accurate and timely manner.
• Develop and maintain working knowledge of all federal, state and local regulations pertaining to hospital billing.
• Monitor accounts to facilitate timely follow‑up and payment to maximize cash receipts.
• Maintain work queue volumes and productivity within established guidelines.
• Provide excellent customer service to patients, visitors and employees.
• Participate in performance improvement initiatives as requested.
• Work with supervisor and manager to develop and exceed annual goals.
• Maintain confidentiality according to policy when interacting with patients, physicians, families, co‑workers and the public regarding demographic/clinical/financial information.
• Communicate problems hindering workflow to management in a timely manner.

• Must be able to sit for extended periods of time.
• Must have reading and comprehension ability.
• Visual acuity must be within normal range.
• Must be able to communicate effectively.
• Must have manual dexterity to operate keyboards, fax machines, telephones and other business equipment.

• Office type environment.

• Excellent oral and written communication skills.
• Working knowledge of computers.
• Knowledge of medical terminology preferred.
• Knowledge of business math preferred.
• Knowledge of ICD‑10 and CPT coding processes preferred.
• Excellent customer service and telephone etiquette.
• Ability to use tact and diplomacy in dealing with others.
• Maintain knowledge of revenue cycle operations, third‑party reimbursement and medical terminology including all aspects of payer relations, claims adjudication, contractual claims processing, credit balance resolution and general reimbursement procedures.
• Ability to understand written and oral communication.