Role Summary :
The Payment Recovery Specialist reviews claims to make sure that payer specific billing requirements are met, follows-up on billing through payment of the claim, answers inquiries, and updates accounts as necessary.
The Payment Recovery Specialist is responsible for analysis of denied reimbursement claims and ensures appropriate insurance coverage for compliance standards and revenue generation.
The Payment Recovery Specialist coordinates with departments and insurance companies to correct errors as necessary.
Role Responsibilities :
- Resolves billed claims and referred denials
- Runs reports to determine upcoming workload
- Performs initial contact (phone, web portal) with payers to validate claim status and reason for denial.
- Extracts data from client patient accounting system necessary to resolve denied claims
- Documents account activity in both the Human Arc and client operating system (posts, dispositions, notes, status, etc.)
- Sorts through and takes appropriate action on incoming client correspondence from insurance companies
- Requests and obtains medical records from client or other documentation from physicians offices to resolve denied claims
- Requests additional information as needed from clients, physicians and / or related providers and patients to resolve denied claims
- Issues appeal letters on non-clinical denials
- Follows up with patient for additional information
- Follows up on all appeals, payments and denials, bringing accounts to resolution with both payer and client
- Communicates pertinent client and payer trends to the Team Leader
- Review payment accuracy for final disposition of account
- Performs filing / scanning as needed on assigned accounts
- Communicates pertinent client information regarding procedures, project status to Team Leader
- Accountable for meeting established productivity measures and goals
- Participates in special projects as assigned
Role Requirements :
- Knowledge of and experience with Hospital Patient Accounting systems; language, flow of work, processes, and procedures
- Strong knowledge of insurance types and associated administrative guidelines for each
- Understanding of hospital revenue cycle and insurance payment methodologies
- Billing process and procedures (including parameters and requirements of billing)
- Electronic billing software
- Understanding of insurance contracts and terminology
- Knowledge of State policies / procedures on determining eligibility and claims processing
- Basic understanding of appeals / denial resolution processing needs
- Strong communication skills and problem-solving ability
- Strong analytical, project planning and organizational skills
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