Reviewer

Position: Payment Reviewer
Position Summary
Reviews all remittance advice to ensure appropriate reimbursement for 3rd party accounts billed. Reviews
HMO/Insurance contract matrix and HIS expected reimbursement amounts to ensure reimbursement is appropriate.
Takes necessary action to resolve account variances and ensure adherence to contract terms.

Essential Functions and Responsibilities Includes the Following :
1. Understands and adheres to the WPH Performance Standards, Policies and Behaviors.
2. Reviews 3rd party remittance advice to ensure proper payment was received from insurance carrier based on contract arrangement.
3. Reviews HIS to ensure expected reimbursement amount is amount received by insurance carrier.
4. Takes necessary action on any reimbursement discrepancies to ensure payments adhere to contract rates and terms.
5. Researches and initiates refunds to patients or insurance carriers as needed.
6. Sends inquiries to patients regarding inaccurate or incomplete information.
7. Escalates issues to management and provider representatives regarding incorrect payer processing and/or contract issues
8. Completes charge adjustments and allowances entries on accounts as needed.
9. Recodes accounts by insurance carrier and plan number and enters into the HIS for re-billing purposes.
10. Processes rejections on accounts denied by insurance carriers.
11. Assists with telephone calls as needed.
12. Contacts insurance carriers as needed for additional payment and or credit resolution.
13. Performs all other related duties as assigned.

Education & Experience Requirements

High School Graduate required. Clerical experience required.
Previous hospital experience preferred.
Ability to use basic office equipment and knowledge of CTR computer terminals a plus.
Medical terminology helpful but not mandatory
Core Competencies

Ability to cooperate with others.
Must be able to speak, write understand and communicate the English language.
Effectively communicate with internal and external customers.
Integrity to handle the confidential aspects of work.
Retains composure under stress.
Physical/Mental Demands/Requirements & Work Environment
May be exposed to chemicals necessary to perform required tasks. Any hazardous chemicals the employee may be exposed to are listed in the hospital's SDS (Safety Data Sheet) data base and may be accessed through the hospital's Intranet site (Employee Tools/SDS Access). A copy of the SDS data base can also be found at the hospital switchboard, saved on a disc.
Must be able to remain in stationary position 50% of the time
The person in this position needs to occasionally move about inside the office to access file cabinets, office machinery, etc.
The person in this position frequently communicates with insurance plans, must be able to exchange accurate information in these situations.