Hospital Claims Analyst

JOB SUMMARY

Under the general direction of the Director of Business Services, the Hospital Claims Analyst will perform accurate/timely filing of initial insurance claims and secondary claims, follow up of claims not paid to assure payment to hospital and/or affiliated entities to maintain adequate cash flow and accounts receivable balance, in accordance with TJC, federal, state, and local guidelines, organizational and departmental policies and procedures. Communicates with medical staff, other departments, and outside agencies while maintaining confidentiality. Position requires self-motivation, creativity, and capabilities to function in a semi-autonomous role within a fast pace and dynamic environment.

Hours: M-F, 8:30am - 5:00pm

STANDARDS OF PERFORMANCE

1. Processes and adjust inpatient and outpatient medical claims in a timely fashion according to departmental quality and production standards.
2. Assists Director of Business Services in researching and determining status of medical claims to assure billed dollars, claims aging, and pend values are consistent with contract provisions.
3. Performs follow up and takes necessary actions required to resolve all errors and findings assessed by Internal Audit and performance improvement plans.
4. Ensures the validity of claims by reviewing files and attached documentation for completeness and accuracy.
5. Identifies patterns in resubmitted and adjusted claims. Identifies errors, trends, and inconsistencies that require revisions to claim guidelines or system modifications.
6. Documents systemic root cause analysis and recommend solutions to Director of Business Services.
7. Resolves claims issues received by researching claim situations and provide timely reports and responses.
8. Enhances department productivity by recommending improvements to workflow processes and organizational structure.
9. Ensures the completeness and accuracy of Standard Operating Procedures by providing feedback to the department director on procedures that require documentation or additional detail.
10. Contributes to the team effort by accomplishing the related goals and results as determined by the Insurance and Billing Department leadership team.
11. Maintains documentation to support avoidance to negative financial, regulatory, and operational impact.
12. Researches and responds to inquiries from various departments.
13. Provide detailed reporting on claims volume, billed charges, savings, etc.
14. Increase subrogation recovery efforts on approved claims.
15. Assist in gathering customer feedback, defining processes, and identifying best practices.
16. Handles PHI and maintains member privacy in accordance with HIPAA standards at all levels.
17. Exhibits proficiency in all realms of insurance billing, including but not limited to managed care and commercial.
18. Exhibits a thorough knowledge of hospital billing formats. Specifically, UB 04’s, 1500’s and contract billing.
19. Review every account on ATB for insurance financial class and review and resolve auto rejected claims. Exception will be Medicaid and Medicare which should be forwarded to Business Services, Medicaid/Medicare primary A/R Analyst. Secondary A/R’s should be forwarded to the Business Services, Secondary insurance, primary A/R Analyst.
20. Add insurance information into system and set to bill.
21. Review all credit balance accounts and process patient refunds.
22. Review all accounts on ATB for correct contractual and non-covered services.
23. Review all accounts on ATB to identify master accounts and test accounts.
24. Review all accounts on PP/ATB regarding denials due to lack of patient response.
25. Review all accounts on ATB and identify and write up any adjustments such as employee discount, pp discounts. Etc., and forward for bad debt processing.
26. Assist in answering phone calls and walk-ins.
27. Must participate in continuing education and training to maintain and improve knowledge and skills as related professional skillset and the patient population EHS serves.
28. Ensure proper infection control, OSHA and safety standards.
29. Exhibits proficiency in all realms of insurance billing, including but not limited to managed care and commercial.
30. Exhibits a thorough knowledge of hospital billing formats. Specifically, UB 04’s, 1500’s and contract billing.
31. Other duties as requested, required, or assigned within scope of job and training.

Minimum Level of Education: Education level equivalent to completion of high school diploma.

Formal Training: claims experience skills including investigation, resolution and operations. Skill and experience in planning, organizing, implementing, facilitating, verbal and written communications. Must possess basic typing skills; have the ability to manage cash and give change; and use proper telephone etiquette.

Licensure, Certification, Registration: None required. Formal classes in Medical Office Procedure, and Medical Billing are preferred.

Work Experience: Two years billing/collection experience in the healthcare field. Intermediate computer skills with word processing and spreadsheet capabilities.

Computer Skills: Intermediate computer skills, including Microsoft Office Suite (Word, PowerPoint, and Excel); scheduling appointments/updating calendars