Overview:

CHI Health strives to care for you the way you care for your patients.

We understand you have personal responsibilities outside of your profession and also care about your well-being.

With you in mind, we offer the following benefits to support your work/life balance:

• Health/Dental/Vision Insurance
• Direct Primary Plan (No copay, no deductible, and access to CHI Health provider 24/7)
• Premium Access to our Family Care Program supporting your needs for childcare, pet care, and/or adult dependent care
• Voluntary Protection: Group Accident, Critical Illness, and Identity Theft
• Employee Assistance Program (EAP) for you and your family
• Paid Time Off (PTO)
• Tuition Assistance for career growth and development
• Matching 401(k) and 457(b) Retirement Programs
• Adoption Assistance
• Wellness Programs
• Flexible spending accounts

From primary to specialty care as well as walk-in and virtual services CHI Health Clinic delivers more options and better access so you can spend time on what matters: being healthy. We offer more than 20 specialties and 100 convenient locations; with some clinics offering extended hours.

Job Summary / Purpose

Under direct supervision, this position is responsible for corresponding with both commercial and government health insurance payers to address and resolve outstanding insurance balances related to coding denials in accordance with established standards, guidelines and requirements. The incumbent conducts follow-up process activities through review of medical records and contact with providers, phone calls, online processing, fax and written correspondence, leveraging work queues to organize work efficiently. Work also includes reviewing insurance remittance advices, researching denial reasons and resolving issues through well-written appeals.

Work requires proactive troubleshooting, significant attention to detail and the application of analytical/critical thinking skills to analyze denials and reimbursement methodologies to bring timely resolution to issues that have a potential impact on revenues.

In addition, the incumbent must be able to communicate effectively with payer representatives and maintain professional communication with team members in order to support denials resolution.

Essential Key Job Responsibilities

1. Applies a thorough understanding/interpretation of Explanation of Benefits (EOBs) and remittance advices, including when and how to ensure that correct and appropriate payment has been received.
2. Communicates effectively over the phone and through written correspondence to explain why a balance is outstanding, denied and/or underpaid using accurate and supported reasoning based on EOBs, reimbursement, and payer specific requirements.
3. Review patient medical record to compare documentation and coding; change coding based on documentation to include diagnosis codes, modifiers, place of service, etc. Communicate with provider to resolve claims that require a written appeal or second level appeal.
4. Resubmits claims with necessary information when requested through paper or electronic methods.
5. Anticipates potential areas of concern within the follow-up function; identify issues/trends and conducts staff training to address and rectify.
6. Recognizes when additional assistance is needed to resolve insurance balances and escalates appropriately and timely through defined communication and escalation channels.
7. Resolves work queues according to the prescribed priority and/or per the direction of management and in accordance with policies, procedures and other job aides.
8. Assists with unusual, complex or escalated issues as necessary.
9. Organizes open accounts by denial type or payer to quickly address in bulk with representatives over the phone, via spreadsheet, utilizing an on-line payer portal, etc.
10. Accurately documents patient accounts of all actions taken in billing system
11. Other duties as assigned by management.