Insurance Follow-up Representative III-MPV Analyst: Austin Regional Clinic

PURPOSE: Responsible for processing follow up actions on denied, unpaid and/or underpaid insurance claims, and responding to health plan correspondence primarily in MPV Phynance. Carries out all duties while respecting patient confidentiality and promoting the mission and philosophy of the organization supported.

ESSENTIAL FUNCTIONS:

· Reviews and edits claims in Follow Up Work Queues as necessary to reflect complete, accurate information.

· Utilize In-Basket to communicate with clinic staff and obtain information and authorization to edit claims.

· Reviews procedure and diagnosis codes to make sure they conform to third party rules and ensure highest possible appropriate reimbursement.

· Researches insurance payments and ANSI Reason Code denials to determine correct posting information.

· Follows up with insurance carriers on problem payments and adjustments.

· Utilizes Payer/Storage Web-sites for claims status or eligibility.

· Opens, closes, and process batches according to departmental guidelines.

· Generates any adjustments necessary to complete posting of payments.

· Uses appropriate Functions when performing actions as described through Account Maintenance.

· Maintains and follows up on accounts appropriately and documents all activities and results through Account Contact.

· Reviews accounts for credits and request refunds to Insurance Companies or Patients as necessary.

· Obtains signature of approval for any adjustments over $250.00.

· Informs and works with management team when all usual attempts to collect from third parties and/or customers have failed to result in adequate reimbursement.

MPV Phynance

· Validates appeal opportunities, creates appeal letters, generates and submits timely appeals, tracks appeals and recoveries and performs regular follow up on outstanding appeals.

Workqueue Maintenance

· Reviews claims for research and follows-up on accounts as assigned in the Follow Up workqueues.

· Manages accounts assigned to the workqueues using Workqueue Ticklers.

· Places account notes in Account Contact to document all activities and results

Correspondence

· Maintains correspondence levels to no more than 7 days backlog.

· Post zero payment EOBs / correspondence using a Payment Posting Batch

· Reviews Workqueue Summary for each correspondence account and completes from Workqueues as appropriate.

· Respond to Patient/Customer to confirm receipt of / or provide resolution to written correspondence.

Registration

· Forwards requests for Registration verification and updates to the Registration Team.

· Adds a Termination date to patient coverage when claim is denied “coverage termed.”

OTHER DUTIES AND RESPONSIBILITIES:

· Access to process claims in Epic Account Maintenance.

· Provide Call-center back-up to Customer Service and Registrations Teams.

· Able to meet performance standards in Patient Registration and Posting.

· Keeps complete, accessible, updated files.

· Verifies insurance eligibility and sets up accounts by account type classifications.

· Provides assistance to coworkers as requested and/or necessary.

· Provides workload statistic reports to management team.

· Responds professionally and effectively to questions from external sources, i.e., customer or carrier, and internal sources, i.e., provider or management team.

· Attends required inservices/training sessions.

· Works overtime when requested by unit/department/clinic procedures.

· Follows rules and regulations of Covenant Management Systems as described in the employee handbook and in the unit/department/clinic procedures.

· Performs other duties as assigned.

· Has consistent and dependable attendance.

MINIMUM QUALIFICATIONS:

Education: High school diploma or equivalent.

Skills/Experience:

· Experience using Microsoft Excel and computer data processing systems.

· At least 2 years of experience working with accounts receivables to include effectively pursuing payments

from carriers and customers.

· Prefer customer service experience.

· Knowledge of and/or experience with billing and collecting from Medicare, Medicaid and Commercial

Insurance.

· Knowledge of and/or experience with procedural and diagnostic coding.

· Knowledge of patient copay vs. cost share responsibility.

· Basic knowledge of insurance contracts and fee schedules.

· Knowledge of legislative and private sector third party regulations and guidelines.

· Ability to sit for extended periods of time at a computer workstation.

· Must have excellent verbal and written communication skills in order to communicate clearly and effectively

to all levels of staff and the public.

· Ten key entry by touch preferred.

WORK SCHEDULE: Monday through Friday from 8am to 5pm