Call Processing Reimbursement Specialist 1 (Hybrid)

Position Summary:

The Call Processing Reimbursement Specialist I is responsible for the complete revenue cycle including billing medical, dental and/or hospital claims, and working directly with members over the phone. They are responsible for the follow-up performed on insurance balances to ensure reimbursement is accurate and received timely. They are also responsible the self-pay collections after insurance and answering billing related questions.

Essential Functions of the Job:

• Demonstrates knowledge and understanding of the San Ysidro Health services and programs to answer questions and direct calls appropriately.
• Review, collect and update patient demographics and take appropriate actions to update changes identified.
• Efficiently and actively provides excellent customer service by properly greeting, listening, assisting, directing, and closing each call.
• Understands, recognizes, and effectively handles unique medical issues, urgent services and patient grievances and follows established protocols to resolve problems or determines escalation to supervisor.
• Log in and be ready to receive or make calls as directed by schedule as wells as utilizing break codes appropriately as defined by the call management system.
• Provides quality, efficient telephone customer service to internal and external customers and route calls to appropriate department for continued assistance as necessary.
• Clearly and effectively communicates with patient/staff via call or electronic message. Takes complete messages that are detailed, concise, spelled accurately and utilize correct medical terminology.
• Responds to all patient or insurance telephone inquiries to ensure timely reimbursement.
• Prepares accounts and encounters for accuracy for billing. Prepare, review, and transmit claims using automated systems and manual paper claim process.
• Provides any required attachments to third party claims including authorizations and EOB'S to ensure timely payment for the third party payer.
• Changes system financial settings once primary insurance has paid to ensure that co-payments and deductibles are generated to guarantors.
• Identify and bill secondary payers.
• Ensures accurate calculation of disallowances and adjustments through analysis of SYHealth contracts, Medicare and Medi-Cal reimbursement schedules and rates.
• Performs adjustment write off(s) keying and posting via computer input after obtaining approval signatures if required.
• Performs timely follow up and appeals on unpaid claims using the system work list and or Remittance Advices, EOBs, and other payment documents.
• Documents all analysis findings, phone calls and correspondence in the online practice management system.
• Must maintain assigned Accounts Receivable at or below goal on a consistent basis.
• The Call Processing Reimbursement Specialist is required to compose professional written correspondence with all internal & external entities.
• Attends meeting and training classes as required by departmental or facility management.
• Will be called upon to perform special projects and participate in internal and external audits that may require some evening and weekend hours.
• Adheres to established departmental and facility policy and procedures, objectives, quality assurance programs, safety, and infection control standards.

Additional Duties and Responsibilities:

• Performs other duties as assigned by the Director of Revenue Cycle, Business Office Manager or Billing Supervisors.

Job Requirements

Experience Required:

• Minimum of 1 years’ experience in a medical billing department.
• Must also demonstrated knowledge of CPT, HCPCs, and ICD-10 coding as well as Medical Terminology.

Education Required:

• High School Diploma or GED equivalent 

Verbal and Written Skills Required to Perform the Job:

• Good oral and written communication skills.
• Provides positive customer service skills.
• Must possess the ability to communicate effectively in English; both verbally and in all written communication.

Technical Knowledge and Skills Required to Perform the Job:

• Experience in billing, CPT codes, and ICD-10, as well as medical terminology.
• Must be able to work independently
• Experience and knowledge with Microsoft Office software
• Math ability to calculate and accurately analyze various accounts

Equipment Used:

• General office equipment to include PC and Software (Excel, Word, Office), phone, fax, etc.

Working Conditions and Physical Requirements:

• This position is intended to be a hybrid role, where the incumbent will rotate working on-site and remotely every other week; additional on-site presence may be required based on business need.
• Sedentary work requires sitting and use of the PC most of the day; occasional standing/walking, reaching, stooping ending, kneeling, crouching; manual dexterity and mobility. 
• Able to work in a noisy setting.
• May be required to work evenings and/or weekends

Universal Requirements:

Pre-employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs. Compliance with all mandated vaccinations and all boosters is a term and condition of employment.