Enrollment & Billing Representative is responsible for the accurate enrollment and billing process for an insurance organization. Maintains related documents, updates corresponding records and responsible for enrollment and billing query. Being an Enrollment & Billing Representative requires a high school diploma or its equivalent. Typically reports to a supervisor or manager. The Enrollment & Billing Representative possesses a moderate understanding of general aspects of the job. Works under the close direction of senior personnel in the functional area. May require 0-1 year of general work experience. (Copyright 2024 Salary.com)
The Case Management Representative (CMR) coordinates the day-to-day operations of Utilization Management by providing all insurance companies with the information required to obtain approved days. Directing all denials and appeals to the appropriate person or team. The CMR will submit reviews in a timely manner for payers. Review, index, and/or respond appropriately to payer communication via OnBase. The CMR provides all communication with the insurance company to obtain approved days for the patients encounter. Serves as the liaison between various departments in the hospital, including HIM, Business Office, physicians' offices, and Access Services. Coordinates Medical Management Tracker, denial log, and TQ reports. This position is responsible for communicating the essential information to obtain approved for bed days from the insurance company. This communication is the driver for the payment received from the insurance company.
Daily Operations
Transcribes data from insurance companies sent via into the electronic medical record.
Enters data in the electronic medical record to ensure correct billing.
Provides notification to the Utilization Review team for any denials.
Sends clinical updates to insurance companies to obtain approval for hospital days.
Communicates with the Utilization Review Nurse any denials received from the insurance company by fax or verbally.
Coordinates the daily operations of Utilization Review, obtains the clinical information and forwards to payors to complete for certification. Completes all incomplete certification for all patients.
Communicates with providers to verify actual dates of services and other information needed to ensure efficient departmental operations.
Closes the encounter with completion of the bed days table and the record is then sent for billing.
Quality
Other Duties as assigned
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