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Billings Clinic Claims Specialists in Malta / Billings, Montana

Claims Specialist I

Reporting structure
* Staff will report to Clinical Coordinator/ Supervisor of the department.
* Clinical Coordinator/ Supervisor will report to the Manager of the department.
* Managers will report to the Director of the department.
* Directors will report to the VP/Chiefs of the department.

PURPOSE/DISTINGUISHING CHARACTERISTICS

Job Summary
The Claim Specialist’s main focus is to obtain maximum and appropriate reimbursement for all claims from government and third party payers. The Claims Specialist is responsible for preparing and submitting timely and accurate insurance claims to government and third party payers, assisting in the implementation of payer regulations and ensuring compliance to the regulatory requirements, and verifying payments and adjustments are appropriately applied to accounts based on government, contract or other regulations or agreements. The Claims Specialist is responsible for appropriate follow up on all accounts pending payment from government and third party payers.

ESSENTIAL JOB FUNCTIONS
* Supports and models behaviors consistent with the mission and philosophy of Billings Clinic and department/service.
* Responsible for submission of timely and accurate claims to primary, secondary, and tertiary insurances for both electronic and paper submission. Generates telephone calls to insurance carriers to follow up on insurance using reports generated for this purpose to ensure the timely collection of money due on the account.
* Audits accounts by verifying that reimbursement amounts are appropriate, coordination of refunds, if appropriate, and coordinating adjustments when necessary, claims appeals or resubmissions, moving balances from insurance responsibility to patient responsibility when appropriate, and reviews and resolves credit balances.
* Ensure that claims have appropriate information on them for submission to insurance companies or agencies by reviewing errors and other prebilling insurance reports/worklists. Analyzes and review claims to ensure that payer specific regulations and requirements are met.
* Prepares and presents verbally and in writing challenges to third party payers for additional reimbursement for denied charges and/or reductions in reimbursement as appropriate.
* Provides guidance and or assistance to the cashiers.
* Provides timely follow-up on correspondence received from the insurance carrier or patient.
* Responds to inquiries from customers/other departments/insurance carriers regarding insurance coverage issues, coordination of benefits, reconciliation of account balances and complaints regarding services received. Initiates appropriate follow-up on outstanding issues.
* Sets up registration and insurance information when necessary.
* Utilizes performance improvement principles to assess and improve quality.
* Identifies needs and sets goals for own growth and development; meets all mandat ory organizational and departmental requirements.
* Maintains competency in all organizational, departmental and outside agency environmental, employee or patient safety standards relevant to job performance.
* Performs other duties as assigned or needed to meet the needs of the department/organization.

Essential Functions Disclaimer
* Supports and models behaviors consistent with Billings Clinic’s mission, vision, values, code of business conduct and service expectations. Meets all mandatory organizational and departmental requirements. Maintains competency in all organizational, departmental and outside agency standards as it relates to the environment, employee, patient safety or job performance.
* Performs all other duties as assigned or as needed to meet the needs of the department/organization.
* Department or Level Specific Duties and Responsibilities

Minimum Qualifications
* High school graduate or equivalent

Experience
* Prior billing and/or patient accounting experience preferred

Cross-Training
* Training will initially be in one primary payer group for either hospital or clinic services and expand into other payer groups once proficiency of the specific billing requirements has been obtained.
Upon demonstration of proficiency in primary payer group, training will be focused and expanded into the payer areas as proficiency is gained. Each functional job area has unique billing and compliance needs.

Cross-Training on Information/ SPECIFIC Systems
* Hospital
* SMS
* MEPS
* Clinic
* Misys
* MEPS
* EMDEON

Knowledge
* Entry level position requires approximately 6 months of training to acquire basic knowledge levels and normally requires 1 to 2 years work experience to gain proficiency, detailed knowledge and interrelationships of Billings Clinic c harging structure, billing procedures, follow-up procedures, government and third party payer regulations and patient accounts information systems.

Analytical Skills
* Ability to analyze non-complex, basic customer inquiries and determine appropriate action in conjunction with supervision.
* Independent Judgement
* Work is performed in accordance with established policies, procedures and regulatory requirements.
* Coordinates follow-up and resolution of problem scenarios with assistance from Level II staff, lead or supervisor or makes referrals as appropriate.
* Ability to determine proper procedures for resolving various basic to semi-complex problems with supervision

Interpersonal Skills
* Ability to incorporate population specific needs and appropriate communication into assigned area of service.
* Interpersonal skills which enable incumbent to appropriately respond to a variety of non-complex customer inquiries and requests, to respond t o non-complex inquiries from the payers.
* Ability to deal with difficult situations in a mature and professional manner.
* Service Recovery

Education
* Project Management
* Leadership

Supervision of Others
None

Process Improvement / Quality Assurance /Risk Management

Fiscal Responsibility
Responsible for financial interest of Billings Clinic through obtaining appropriate and timely government and third party reimbursement. Errors could result in reduced or lost reimbursement and/or negatively impact customer service or public’s perception of Billings Clinic

On-Call Responsibility
* Technical Skills
* Study Assignments
* On-call Responsibility
* Information Systems
* Project Management /Requirements gathering and analysis Skills
* Resource
* Organiza tional Skills
* Community/Patient Education
* Professional Affiliations
* Overall Performance

Duties
* Patient Care
* USP-797 Media Fill Testing, Environmental Sampling & End Product Testing Requirements
* Promotional Guidelines
* Essential Functions
* Service/Sales Time Allocations
* Pay Plan Components
* Specimen Examination and Submission Authorization
* Research or Process Improvement, Committee or Council Participation
* Criteria/Role/Activity

KNOWLEDGE OF / SKILLS / ABILITIES / COMPLEXITIES AND DIFFICULTIE

Disclaimer
* Billings Clinic policy and procedures, both organizational and departmental
* Personal computers, hardware and software
* Billings Clinic Code of Conduct
* Billings Clinic’s Compliance and Integrity Program
* HIPAA and confidentiality requirements
* Patient’s rights
* Customer service techniques and Personal Service Excellence (PSE)

Knowledge, Skills and Abilities
* Billings Clinic policy and procedures, both organizational and departmental
* Billings Clinic Code of Business Conduct
* Billings Clinic Corporate Compliance Program
* Personal computers, hardware and software & printers
* HIPAA and confidentiality requirements
* Patient’s/resident’s rights
* Medical terminology
* Customer service techniques and Personal Service Excellence (PSE) skills
* Office procedures, record and bookkeeping practices
* Third party insurance reimbursement methodology and billing requirements
* Basic collection procedures
* Professional communication skills, both verbal and written
* Basic typing at 45 WPM with accuracy
* Basic ten key
* Basic computer
* Time management, organization and prioritization
* Interpersonal relationships
* Incorpor ate population specific needs into all aspects of communication and patient care
* Communicate clearly and effectively, both verbal and written
* Establish and maintain collaborative relationships
* Work effectively in a team environment
* Work independently with minimal supervision
* Remain organized and focused when dealing with frequent interruptions and competing priorities
* Respond calmly and effectively to sensitive and difficult situations
* Concentrate and pay close attention to details
* Utilize time management concepts and maximize time effectively
* Maintain flexibility to adapt to a variety of work load assignments
* Interpret policies and procedures, identify non-compliance and take appropriate action
* Work with numbers and perform basic to complex mathematics
* Analyze accounts and compare to contracts, agreements and government regulatio ns.
* Position requires high degree of confidentiality due to access of financial and medical information
* Complexity of duties comes in understanding the policies and procedures, which change with great frequency, to make independent decisions that will not jeopardize the collect ability or amount received by Billings Clinic and for prioritizing the work volumes appropriately.
* Concentration on organization since this position handles a large volume of paper work.
* Concentration on detail when dealing with numbers and mathematical calculations where errors are critical to our customers and our business.
* A complete understanding of Billings Clinic charges, billing structures and the rationale behind them so appropriate answers can be given to the customer, public, and third parties.
* A thorough understanding of the laws governing authorized signatures, release of information, and release of diagnosis, disclosure regulation and billing and collection authority.
* Concentration as the job requires high productivity, yet has many and frequent interruption factors including telephone calls.
* A thorough understanding of contracts, arrangements, agreements and government regulations that govern insurance claims to ensure compliance and proper reimbursement.
* Errors are costly to Billings Clinic to the extent of financial loss and damaging customer’s attitude toward the facility.

MINIMUM QUALIFICATIONS

Education
* Min/Preferred Education Level Description
* Minimum High School or GED High school graduate or equivalent

Years Of Experience
* Minimum Years of Experience Comments
* 1 One year of previous office experience

Certifications
* Certification Title Required To Have By Comments

Licenses
* License Title Required To Have By Comments
* Other

Minimum Qualifications
* Patient accounts or insurance billing experience preferred
* Or an equivalent combination of education and experience relating to the above tasks, knowledge, skills and abilities will be considered

WORKING CONDITIONS
* Working Conditions 2
* Condition Comments
* Normal office environment
* Working Conditions List

Blood Borne Pathogen Category
Category III: Tasks that involve no exposure to blood or body fluids or tissues, and Category I tasks are not a condition of employment.

Airborne Contaminant Category
Category III: Not at risk for exposure to airborne contaminants.Job Analysis

Job Description Disclaimer
The above is intended to describe the general content of and requirements of the performance of this job. It is not to be construed as an exhaustive statement of duties, responsibilities or requirements.

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