Job Description
Job Description
Department: Patient Financial Services
Job Title: Claims Specialist
Reports to: Revenue Integrity Supervisor
Schedule: Monday – Friday
POSITION SUMMARY
- Responsible for maintaining the flow of electronic (and paper) claims between various software/programs ensuring all data is transmitted in an accurate and timely manner.
OVERVIEW
- The evaluation is to ensure individual performance, departmental goals and organizational goals are aligned. It is designed to support communication between the manager and the employee. Employee perception of their own performance is very important. To maximize the benefit of this process, both the manager and the employee participate in the evaluation process.
QUALIFICATIONS
- Knowledge, Skills and Abilities
- Excellent customer service skills.
- Reads and understands the English language.
- Ability to think critically and analytically with little or no supervision
- Ability to work effectively in situations of high stress and conflict and communicate goals and outcomes.
- Ability to process information and prioritize
- Possesses exceptional verbal and written communication skills
- Possesses independent work habits, is self-reliant and self-directed
- Ability to learn, adapt, and change as required by the job functions
- Ability to maintain absolute confidentiality of material and information accessed and reviewed
- Basic computer literacy
- Ability to move freely, reach, bend, and complete light lifting
- Ability to use good body mechanics while performing daily job functions and ability to follow specific OSHA guidelines
- Ability to maintain attendance to meet standard job practices
- Education
- High School diploma required, with some college level courses desirable.
- Preferably C.P.A.R. certified but not required.
- Licensure Preferred: CCS, CPC, CCA, RHIA, RHIT, AAPC
- N/A
- Experience
- Interpersonal skills
- Essential technical/motor skills
- Essential physical requirements
- Light: Exert up to 20 lb. of force occasionally and/or up to 10 lb. of force frequently - greater than 75%
- Medium: Exert 20 – 50 lb. of force occasionally and/or up to 15 lb. of force frequently - 1-24%
- Essential mental requirements
- Essential sensory requirements
- Other
- Must have good oral and written communications and the ability to train personnel.
- Must possess analytical and problem-solving skills and the ability to work and communicate effectively with departmental supervisors, directors, and upper management personnel.
- Must possess excellent interpersonal skills and high adaptability to a changing environment.
- Knowledge of software processes, ability to handle multiple projects simultaneously, training and troubleshooting skills, project management skills, customer service skills, have the ability to work under little supervision.
- Equipment used
OTHER QUALIFICATIONS
Exposure to hazards (body fluid exposure level)
Age of Patient Populations Served
JOB SPECIFIC DUTIES AND PERFORMANCE STANDARDS
Below are those tasks, duties, and responsibilities that comprise the means of accomplishing the position’s purpose and objectives. These are critical or fundamental to the performance of the position. They are the major functions for which the person in the position is held accountable. The following are the essential functions of the position, along with the corresponding performance standards.
- Daily balance and maintain spreadsheet to ensure claims from the host system to claims system to contract management system are in balance and have been imported correctly in all systems.
- Must maintain knowledge based on all the billing and collection areas to perform a job at a satisfactory level.
- Keeps abreast of all regulations and standards to ensure compliance with orders of directives issued by duly constituted governmental/regulatory agencies or third-party payers. This covers such areas as billing reporting procedures and development of data to meet the requirements of PP billing and cost reporting.
- Communicates and participates in the educational programs for all staff, as needed.
- Keeps Supervisor well-informed of any issues identified with systems and communicates with staff and coworkers of any issues that may interfere or delay accurate and timely follow up or submission of claims.
- Daily review and work 277s, 278s, Medicare returned to provider claims (RTPs), late charges and combined billing.
- Log support cases for issues related to systems.
- Attending seminars and workshops related to billing policies and procedures as well as software systems used in the department.
- Handles requests from staff or management in a prompt manner.
- Create rules in claims system for efficient billing.
- Committed to achieving excellent customer service and operational performance.
- Keeps Supervisor informed on the status of his/her work.
- Responsible for all other functions as required and directed by the Supervisor and/or Director.
- Attends all mandatory and department-specific education and training programs as required.
- Attends all required education and training and can describe his/her responsibilities related to department safety and specific job-related hazards.
- Has met all required competencies for the evaluation period as evidenced by job specific competency evaluations...
- Other Performance standards: score
- Exhibits of leadership characteristics vital to the success of CRMC.
- Acts as an agent for change from traditional practices and pursue positive changes.
- Committed to achieving excellent customer service and operational performance.
- Demonstrates a constructive approach during all interactions with staff and management toward the organization.
- Actively participates, as evidenced by project involvement related to committees' purpose/ responsibilities, as evidenced by bimonthly project updates or monthly operational reports.
- Maintain patient confidentiality of information to assure Patient Rights and the rights of others are protected in accordance to policy and procedure. Release information in accordance with established privacy guidelines.
- Offers workable ideas, concepts and techniques to improve productivity
- Willing to attempt new job duties, tasks, etc.
- Maintains regulatory requirements including all state, federal and Joint Commission regulations related to Patient Financial Services and, as appropriate, to the facility.
- Accept assignments as a preceptor for new staff.
- Attends 75% of scheduled meetings as evidence by minutes and/or agenda.
- Operates assigned equipment and performs all procedures in a safe manner as instructed.
- Maintains work area and equipment in condition required by department standards.
- Demonstrates proper body mechanics in all functions.
- Participates in annual education programs.
- Wear and/or use appropriate safety equipment.
- Interacts with all of the above in a considerate, helpful, and courteous manner.
- Fosters mature professional relationships with fellow employees in a courteous, friendly manner as measured by management of observation and peer input.
- Conducts all work activities with respect to the rights and wishes of patients, visitors, families, and fellow employees.
- Maintains confidentiality of all hospital and patient information at all times
- Presents neat appearance in proper attire and identification as required by hospital policy.
- Demonstrates the ability to use the computer system(s)
- Completes work assignments on time/readily accept assignments as observed by supervisor/director
- Reports to work on time, is at work as scheduled & attend to personal affairs to avoid conflicts with work, as observed by director.