Specialist, II RCM – Claims Submission

Job Description:

The RCM Claim Submission Specialist II, RCM role performs revenue cycle management activities for designated accounts. The Specialist assists colleagues and global partner teams with projects and assignments related to their RCM department. The Specialist will assist within the claim submission functions, including the initiation of goals and procedures, overseeing daily operations, and coordinating efforts to expedite clean claim submission. The Specialist will be asked to elevate issues with payers, perform and review audits, report trending and avoidable items as appropriate, and participate in the development and updating of unit policies, workflows, and procedures. The specialist will be responsible for ensuring that daily, weekly, and monthly tasks are accomplished effectively and in a timely manner.
This role will specifically support the Claims Submission Departmental responsibilities listed below.

• Complete inventory assignment(s) in a timely manner with minimal assistance and oversight.
• Aid with client-specific workflow process.
• Monitor work quality pertaining to client protocols, against audit tools and client and internal documented procedures.
• Actively participate in vendor management, global partner, and client meetings as requested by Management.
• Assist management with the preparation and documentation of the issues, trends, and other performance monitoring tools.
• Serve as a front-line back-up to ensure work processes continue to flow when global partners and/or assigned staff are not available.
• Develop and maintain positive working relationships and partner with internal and external customers, vendors and payers by providing superior customer service.
• Maintain the confidentiality of patient information in accordance with posting guidelines, company policy & procedure, and Health Insurance Portability and Accountability Act (HIPAA) regulations.
• Actively engage management with on-going client specific feedback to help prepare for Client Management meetings.
• Lead department and client-specific projects with small scope as assigned.
• Generate standard/ad hoc reports as needed, create action plans, and contribute to development of Standard Operating Procedures (SOPs).
• Perform other duties that support the overall objective of the position.

Department-specific responsibilities:

Claims

• Perform and collaborate with global partners to ensure timely claims submission for clients.
• Collaborate with technology vendors supporting claims management.
• Generate relevant reporting for management and clients on claims submission and SLA adherence.
• Facilitate, prepare, and maintain electronic claims enrollments with government, commercial, and third party payers on behalf of all clients.

Coding

• Review and/or audit patient charts to confirm HCPCS and ICD codes are appropriately assigned and sequenced according government regulations and insurance payer guidelines.
• Verify provider documentation accurately supports the diagnoses, services, and treatment as billed on the patient’s encounter.
• Utilize AAPC, Encoder Pro, and other medical coding resources to identify and confirm accurate codes for claims submission.
• Utilize and provide guidance with respect to National Correct Coding Initiatives (NCCI) to reduce improper coding for Medicare Part B claims.
• Collaborate with client to identify documentation inefficiencies and educational opportunities for providers to ensure timely and accurate medical charting.

Credentialing

• Research, collect and verify documentation required to initiate verification, enrollment and privileging with healthcare insurers, providers and accreditation organizations.
• Complete enrollment, source verification and hospital privileging processes/requirements within the allotted timelines in accordance with payer & state requirements, and contracted service level agreements (SLAs).
• Review and audit provider status as required; verify any disclosed or discovered disciplinary or malpractice actions.
• Maintain communications between client and NextGen to ensure the credentialing activities to ensure high client satisfaction.

Insurance AR

• Review and/or audit accounts to determine status and appropriate action required.
• Research and follow-up on denials and requests for additional information.
• Receive, research, and respond to correspondence from insurance companies, attorneys, and patients.
• Use facility correspondence websites, phone, and/or correspondence to contact payers regarding reimbursement for unpaid accounts.
• Identify, verify, and document account adjustments according to established policies and procedures.
• Collaborate with management to identify payer trends and non-payment issues.

Patient Services

• Review and complete patient account balances for collections per client specifications. 
• Review and complete patient balance verification, review Explanation of Benefits (EOBs) to validate patient responsibility and payment posting.
• Converse with customers as needed to obtain information, identify problem(s), and provide assistance.
• Process patient payments accurately and in a timely manner.

Payments

• Post payments and adjustments received from insurance carriers, patients, and collection agencies with accuracy and efficiency while utilizing the appropriate fee schedule/policy.
• Review and interpret explanation of benefits (EOB) from insurance carriers to post appropriate payment and denial codes.
• Identify incomplete information necessary to post remittance and take the necessary steps to resolve questions, inconsistencies, or missing data.
• Facilitate, prepare, and maintain electronic remittance and EFT enrollments with government, commercial, and third party payers on behalf of all clients.

Education Required:

• High School Diploma or General Educational Development (GED).

Experience Required:

• 2-4 years of experience in medical billing and/or collections in a healthcare or insurance environment.
• Or, any combination of education and experience which would provide the required qualifications for the position.

License/Certification Required:

• Coding
  •    Certified Coding Specialist (CCS-P), Certified Professional Coder (CPC), or Certified Coding Associate (CCA), required from AHIMA or AAPC; or licensure equivalent

Knowledge, Skills & Abilities:

• Knowledge of: Knowledge of healthcare carriers and payer requirements. Knowledge of Microsoft Office Suite (Word, Excel, Outlook and PowerPoint) with intermediate skill level. Knowledge of Windows based programs. Knowledge and understanding of practice management software. 
• Skill in:  Effective communication with cross-functional team members, peers, and management; providing customer service to internal and external clients; problem solving, analytical, and critical thinking; working as member of a team; communicating clearly, concisely, and effectively; establishing and maintaining effective working relationships.
• Ability to:  Build strong internal and external relationships; work independently with limited direction and/or guidance; maintain confidential information; work in a fast-paced environment; stay organized, prioritize workload, multi-task, and meet deadlines.

The company has reviewed this job description to ensure that essential functions and basic duties have been included. It is intended to provide guidelines for job expectations and the employee's ability to perform the position described. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate. This document does not represent a contract of employment, and the company reserves the right to change this job description and/or assign tasks for the employee to perform, as the company may deem appropriate.

NextGen Healthcare is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.