Mission Statement: MercyOne serves with fidelity to the Gospel as a compassionate healing ministry of Jesus Christ to transform the health of our communities.
MercyOne Vision Statement:
Mercy Health Network will set the standard for a personalized and radically convenient system of health services.
MercyOne Cultural Beliefs:
I benefit from and strengthen Mercy Health Network.
Your experience. My responsibility.
I own my actions to deliver our key results.
I make improvements every day for those we serve including each other.
I imagine and embrace bold new ideas to revolutionize health.
Job Summary: The Reimbursement Specialist is responsible for maintaining, researching and resolving reimbursement issues related to contracted and non-contracted claims. These responsibilities include review of claims where payment has been made, calculation of expected reimbursement, segregation of insurance and patient responsibility, identification of actual underpayments and incorrect denials, follow-up, recovery and timely reporting.
Essential Position Expectations:
1. Determines appropriate reimbursement by applying applicable reimbursement methodology and rate schedules, as determined by hospital contractual arrangements.
2. Performs the necessary tasks to recover reimbursement due to underpaid or denied claims and documents recovery steps and other applicable information in Managed Care database and patient accounting systems.
3. Evaluates and understands contractual language and health plan payment policies as it relates to payment compliance, reimbursement methodologies, and appeals processes.
4. Applies basic understanding of medical coding systems affecting the adjudication of claims payment. These include ICD-9, ICD-10, CPT, HCPCS, DRG, APG, APC, and revenue code structures.
5. Demonstrates proficiency with various reimbursement methodologies including, but not limited to, Per-Diem, DRG, fee schedule, percentage of charges, and stop loss.
6. Adept in hospital and insurance reimbursement and billing concepts and procedures, as well as laws and regulations affecting payment compliance and underpayment recovery.
7. Communicates with payer representative to ensure payer recovery task completion.
8. Collects and tracks team monthly recovery dollars.
9. Maintains the ability to understand and utilize a complex and highly sophisticated billing system and related programs.
Knowledge & Skills:
1. Coordinate to engage people and technology to complete payment recovery tasks.
2. Strong skills in health care claims coding and payment process.
3. Strong written and verbal communication.
4. Skills in management and interpretation of data.
5. Strong microcomputer skills (including spreadsheet, database, and word processing software)
6. Read an interpret contract language and reimbursement mechanisms.
7. Develop and maintain positive working relationships with senior management, physicians, hospital staff, and managed care company representatives.
8. Ability to communicate effectively and professionally with all levels of staff and customers
9. Knowledge of health care systems and inter/intra-relationships; hospital finance, revenue cycle, and information systems; complex managed care concepts and processes; health insurance pricing and associated benefit designs and provider billing and claims processing
Education: High school graduate plus medical office /claims billing past work knowledge required. Two year degree in business or related healthcare field preferred.
Experience: Minimum of two (2) years prior experience working with claim denials, insurance payer reimbursement policies and/or contracts required. Background in financial healthcare reimbursement is required, including an understanding of diagnosis and procedure coding, billing practices, and payment methodologies.
Managed care knowledge preferred. ICD 10 certification preferred.
- Requisition ID: 2019-R0248150
- Schedule: Full-time
- Shift: Day Job
- Market: Mercy Medical Center
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