Account Specialist

Job Summary

Responsible for processing insurance claims. Coordinates collections and delinquent unpaid accounts. Oversees claim processing. Investigates billing problems and assists with error resolution.

Accountabilities

• INSURANCE RESPONSIBILITIES:

  A. Assists in the processing of insurance claims including Medicaid/Medicare claims.

  B. Collects and enters patient's insurance information into database.

  C. Assists patients in completing all necessary forms.  Answers patient questions and concerns.

  D.  Reviews and verifies insurance claims.  Requests refunds when appropriate.

  E.  Processes Medicare correspondence, signature, and insurance forms.

  F.  Follows-up with insurance companies and ensures claims are paid within timeframes as outlined in MA policies and procedures.

  G.  Resubmits insurance claims that have received no response.

  H.  Answers telephone, screens calls, takes messages, and provides information.

  I.  Maintains files with referral slips, Medicare authorizations, and insurance slips.

• COLLECTION RESPONSIBILITIES:

  A.  Identifies delinquent accounts, aging period and payment sources.  Processes delinquent unpaid accounts by contacting patients and third party reimbursers.

  B.  Reviews each account, credit reports and other information sources such as credit bureaus via computer.

  C.  Performs various collection actions including contacting patients by phone and resubmitting claims to third party reimbursers.

  D.  Evaluates patient financial status and establishes budget payment plans.  Follows and reports status of delinquent accounts.

  E.  Reviews accounts for possible assignment makes recommendation to Credit Manager and prepares information for collection agency.

  F.  Assigns uncollectible accounts to collection agency or attorney via clinic Credit and Collection policy.  Contacts lawyers involved in third-party litigation.

  G.  Answers inquiries and correspondence from patients and insurance companies.  Develops collection letters.

  H.  Identifies and resolves patient billing complaints.  Researches credit balances.

• CLAIMS RESPONSIBILITIES:

  A.  Oversees claim processing and payments to third party providers.  Answers associated correspondence.

  B.  Monitors charges and verifies correct payment of claims and capitation deductions.

  C.  Sends denial letters on claims and follow-up on requests for information.

  D.  Audits and reviews claim payments reports for accuracy and compliance.

  E.  Researches and resolves claim and capitation problems.

  F.  Maintains timely provider information in physician files.   

  G.  Maintains insurance company manual and distributes information to staff on updates and changes.

  H.  Maintains required databases and patients accounts, reports and files.

  I.   Resolves misdirected payments and returns incorrect payments to sender.

  J.  Answers patients inquires regarding account balances.

  K. Appeals denied claims adhering to payer policy while communicating with MAMC department for further assistance with claims resolution as appropriate.

  L.  Works all assigned claims within designated time frame to ensure timely and appropriate payment

• BILLING RESPONSIBILITES:

  A. Researches all information needed to complete billing process including getting charge information from physicians.

  B.  Works with other staff to follow-up on accounts until zero balance or turned over for collection.     

  C.  Assists with coding and error resolution.

  D.  Maintains required billing records, reports, and files.

  E.  Investigates billing problems and formulates solutions.  Verifies and maintains adjustment records.

  F.  Maintains and enhances current knowledge of assigned payers with regard to guidelines for billing

  G.  Provides training to front office staff when hired and retraining as needed or requested with regard to a specific payer rules and guidelines for physician billing.

  H.  Recommends changes to departmental processes as necessary to maximize operational effectiveness of the revenue cycle.

• MISCELLANEOUS:

  1. Maintains strictest confidentiality.

  2. Participates in educational activities.

  3. Performs related work as required.

  4. As representative of Prisma Health Clinical Department, is expected to maintain neat and professional appearance, demonstrate commitment to serve at all times and uphold guidelines set forth in office manual.