Medical Policy Specialist jobs in Springfield, IL

SUMMARY:  Under the general supervision of the Director of Business Office Services, the Reimbursement Specialist is responsible for timely billing functions, including posting of charges, electronic and paper insurance billing, and collecting accounts receivables.  The Reimbursement Specialist also conducts training, serves as a primary resource for billing system changes, responds to patient inquiries and resolves problems with third party payors.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

1. Business Office Duties
   1. Registers new patients, obtains appropriate insurance and billing information, and updates information as needed.
   2. Explains billing policies/procedures and insurance benefits to patients.
   3. Generates documentation for patients with private cancer insurance policies as needed.
   4. Responds to patient inquiries (on-site visits and per phone), including researching relevant information, contacting payors on behalf of patients, and informing patients of the outcome.
   5. Serves as a resource person for physicians, staff and patients/family/significant others regarding insurance and billing issues and questions.
2. Reimbursement Duties
   1. Codes procedures and diagnosis.  Reviews charts and abstracts data from patient records for documentation to support charges and services, analyzes source documentation to determine diagnoses, and selects codes for optimal reimbursement.
   2. Posts charges for services, including charges for office visits, physician services, laboratory testing, treatments, etc.  Reviews encounter form, nurse notes, and pharmacy lists for completion, enters charge ticket data, batches charge tickets, files completed batches, and posts charge adjustments.
   3. Processes a variety of insurance billing, including primary, secondary and third party payors.  Verifies claim status, electronically submits claims, sort paper claims according to third party payor, attaches required documentation and submits claims to appropriate payor locations.
   4. Receives and posts payments and adjustments, including receipts from insurance groups, patients, and other organizations.  Sorts payment receivables, reviews EOBs and RAs for payments and adjustments, posts line item payments to corresponding charges. Responsible for balancing receipts and bank deposits.
   5. Reviews returned, disputed or rejected claims and resolves claim problems with third party payors.  Generates aged account reports, follows up with payors for claim status, provides requested information and clarifies documentation, and submits revised claims as necessary.  Reports unresolved accounts to the supervisor.
   6. Reviews patient account to ensure monthly statements are mailed to the patient. Pre-screens patient balances for collection agency placements.
   7. Analyzes patient aged accounts.  Generates aged patient account reports, reviews past due accounts, contacts patients to request outstanding balances, and documents patient payment arrangements.  Reports unresolved accounts to the supervisor.
   8. Maintains a working knowledge of CPT-4, ICD-9 / ICD-10 CM, and HCPCS coding systems, governmental regulations, protocols and third party requirements, as well as compliance issues, related to billing and billing documentation.
3. Professional Communication
   1. Maintains confidentiality in matters relating to all aspects of employment, including patient/family/significant other confidentiality.
   2. Interacts with patients/family/significant others with a variety of developmental and sociocultural backgrounds.
   3. Maintains professional relationships and conveys relevant information to other members of the health care team.
      1. Internal Contacts:  Physicians, nursing staff, laboratory staff, pharmacy staff, office staff, other Business Office staff, etc., and staff at other CCSI facilities.
      2. External Contacts:  Insurance representatives, Medicare representatives, coding specialists, hospitals, other physician offices, hospice staff, etc.
   4. Relays information appropriately over telephones, facsimiles, e-mail, and other communication methods, and follows-through as needed.
   5. Communicates appropriate information to physicians, supervisors, and/or other members of the healthcare team as needed, and follows-through on physician orders and requests.
4. Teamwork
   1. Works collaboratively as a health care team member.
   2. Assists with tasks necessary for the general operation and organization of the Business Office.
   3. Maintains positive attitude with patients, family/significant others and coworkers.

1. Professional Development
   1. Attends staff meetings and mandatory inservices.
   2. Participates in continuing education opportunities.
   3. Contributes to the quality of patient services and participates in quality improvement initiatives.

OTHER DUTIES:

1. Complies with all applicable safety and health regulations, policies and procedures.  Complies with established personal protective equipment requirements necessary for protection against exposure to blood and body fluids, other potentially infectious material, chemical disinfectants, and other hazardous substances.
2. Performs other duties as assigned.

EDUCATION/QUALIFICATIONS:  High school graduate or equivalent. Previous experience in medical billing, coding, collections and training / teaching experience.  Must take EPIC training and successfully pass required tests.

KNOWLEDGE/SKILLS/ABILITIES:  Knowledge of medical terminology, anatomy and physiology, clinical medicine, diagnostic tests, radiology, pathology, pharmacology, and other medical specialties related to medical oncology/hematology.  Extensive knowledge of CPT-4, ICD-9/ ICD-10 CM, and HCPCS coding systems, governmental regulations, protocols and third party requirements, as well as compliance issues related to billing and billing documentation.  General knowledge of basic manual and computerized accounting and billing systems.  Knowledge of various teaching and training techniques which can be applied in different learning situations.  Verbal and written English communication skills.  Eye, hand, and auditory coordination.  Basic computer skills.  Problem solving and prioritization skills.  Ability to work independently with minimal supervision and as part of a team; ability to work under pressure with time constraints; ability to meet deadlines and work with frequent interruptions; ability to concentrate, provide close attention to detail, and handle multiple tasks simultaneously.  Ability to adapt to an individual’s learning needs and requirements; ability to grasp billing system concepts and clearly explain their application; ability to demonstrate patience and support throughout learning experiences; ability to research and clarify system issues.  Ability to maintain professional attitude at all times; ability to handle telephone and face-to-face contact with patients, physicians and other staff.  Ability to function in a sometimes demanding and fast-paced work environment related to changing patient needs, including work with patients with acute, chronic, and complex disease processes and those who are dying.  Understands and practices patient confidentiality.  A positive attitude towards health care team members and diverse patient populations.

PHYSICAL REQUIREMENTS OF JOB:  Standing, walking, sitting, carrying, pushing, pulling, lifting, bending, stooping, squatting, crouching, twisting, reaching, handling, kneeling, and wrist and digital dexterity.  Involves significant degree of data entry.  Involves significant degree of sitting, and involves standing or walking for brief periods of time.  Speaking, hearing, and visual acuity to communicate with patients, physicians and other health care professionals; use telephone system; and operate office equipment and computers.  Exerting force (frequently up to 10 pounds and occasionally up to 20 pounds or more) to lift, carry, push, pull or otherwise move objects, including office supplies, medical charts, billing forms, etc.  Limited driving.

MENTAL DEMANDS:  Must be able to work under stress and adapt to changing conditions.  Must be able to concentrate and focus on details.  Must be able to prioritize requirements of the Reimbursement Specialist functions with additional training responsibilities.

WORKING CONDITIONS:  Normal medical office environment.  Job duties involve minimal potential for exposure to blood and body fluids, chemical disinfectants, and limited exposure to chemicals such as cleaning disinfectants and toners for office equipment.