Claims Specialist

Position Summary

Key Functions & Responsibilities

• Review and analyze encounters to ensure completeness, accuracy, adherence to all system edits (both core system and clearinghouse), and in compliance with all State, Federal, and/or contracted payer rules, terms, regulations, and guidelines.
• Ensures claims are processed in a timely manner, adhering to a standard of claim submission within five (5) days from the date of service, and follows up with individual and/or providers in those situations exceeding five (5) days from the date of service.
• Ensures any claims which are rejected by the clearinghouse, or the payer are addressed, resolved, and resubmitted with corrections.
• Addresses all denials from individual insurers in a timely, efficient, and collaborative manner, communicating with the health centers and support center personnel to effectively challenge denials and reverse the denial decision.
• Files appeal of denials in a timely and professional manner within the specified timeframes as published by regulations, rules, or guidelines of the payer.
• Responds in a timely and professional manner to all patient, insurance, or professional inquiries and concerns.
• Exhibit and apply knowledge of Commercial Indemnity guidelines in the processing, adjudication, and payment of claims.
• Maintain current understanding and application of all Medicare and state Medicaid compliance requirements regarding avoidance of allegations of fraudulent or false claims.
• Maintain productive and efficient communication with third-party payers which achieves expeditious claim adjudication and payment.
• Maintains consistent and timely follow-up with third-party payers and patients (as applicable) in unpaid claims beyond the expected payment date, ensuring each account is clearly and concisely documented with all efforts to expedite payment.
• Utilize online claim status applications in an effective and efficient manner in managing account follow-up.
• Make necessary adjustments to account balances with prior authorization from management to ensure the integrity of the account balance.
• Checks each insurance payment to ensure accuracy and compliance with contract discount terms.
• Evaluates patient financial status and established budget payment plans or eligibility for Sliding Scale consideration.
• Must ensure open and constructive coordination with health center personnel in maintaining accuracy in data elements and processing crucial to effective claims processing and account resolution.
• Must ensure adherence with all HIPAA Regulations and Compliance Regulations ensuring the protection of PHI (Patient Health Information).

Minimum Qualifications

• Minimum High School diploma, an AA or BS degree preferred or commensurate experience.
• Must have at least 2 years of relevant work experience in a Physician Practice/Hospital-based Physician Center/FQHC setting or can have an equivalent combination of training and experience to perform functions outlined for this position.
• Strong attention to detail.
• Must be familiar with hospital and or physician coding.
• Strong customer service skills - bi-lingual (English/Spanish) is a plus.
• Must be assertive and goal oriented.
• Familiarity with computerized systems is required.
• Must be a willing participant in ongoing educational activities and a contributing participant in staff meetings.
• Working on-site is an essential duty for the job.

Why Work at CCI?

• Extensive benefits plan
• Generous PTO Plan
• 403B Retirement Plan + Employer match up to 4%
• Tuition Reimbursement
• Continuing education assistance; can be used toward obtaining certifications, renewal of certifications, or possible conference attendance.
• Our providers are insured for malpractice under the Federal Tort Claims Act.

** CCI Health Services is an Equal Opportunity Employer **