Senior Officer - Insurance Submission

Job Summary

The Senior Officer - Insurance Submission will adjudicate incoming claims in accordance with policies, procedures, and guidelines, as outlined by The View Hospital payer contractual agreements; within mandated timeframes; and according to rates as reflected in respective paper contracts.

Job Responsibilities 1

Accurately provides information to all incoming inquiries regarding claims, provider contracting and reimbursement, product information, procedures, and regulations.

Efficiently maneuvers through various computer systems and on-line resources in retrieving information while responding to customer inquiries and processing member, provider, and internal stakeholders.

Assists in managing claims inventory to ensure that claims are adjudicated in an accurate and efficient manner.

Effectively ensures that detailed electronic records are maintained by accurately documenting all actions taken.

Meets measurable Department standards as they relate to call quality, claim accuracy and efficiency measures as well as meets teamwork, ownership, and professional development goals.

Learns, retains, and updates one's knowledge of a wide variety of product information and internal processes and procedures, while adhering to CMS rules and regulations.

Efficiently utilizes all resources to ensure they are easily accessible when providing information to a client, or supporting a junior teammate, or manager.

Performs thorough review of pending claims for billing errors and or questionable billing practices that might include duplicate billing and unbundling of services.

Responsible for manually correcting system generated errors prior to final claims adjudication.

Be proactive and articulates findings and potential solutions.

Reviews requests submitted by customer service team timely and follows up with providers as necessary and directed by management.

Job Responsibilities 2

Pre-screens all claim types for appropriate coding and documentation (including but not limited to CPT, HCPCS, ICD-10 coding).

Correctly adjudicates claims for contracted/non-contracted providers and applies policies and procedures to confirm that claims meet criteria for payment and follow contractual guidelines.

Reviews respective coding (i.e., CPT, HCPCS, ICD-10) to ensure that claims are billed in compliance with MOPH standards and correct coding guidelines and payer standards.

Verifies presence of all required data fields and that applicable medical records are included/reviewed (where required).

Refers claims for medical claim review as necessary/applicable.

Identifies and refers potential fraud and abuse cases to the Compliance Department.

Communicates identified trends to the Team Leader for use in development of contracted provider training programs.

Identifies opportunities for claims adjudication process improvements.

Manages multiple tasks and prioritizes work to adhere to deadlines and identified time frames.

Reads, writes, and communicates at a professional level.

Performs other duties and responsibilities as may be assigned.

Displays actions that align with the Hospital Vision, Mission, and Values.