Formal Job Description:
The main function of the claims specialist is to analyzing claim denials, working with payers to resolve denials, tracking all denials by payer and denial category, trending recurring denials, and recommending process improvement or system edits to eliminate future denials.
Responsibilities:
• Research and re-bill unpaid claims
• Research and resolve accounts appearing on Follow-up Reports.
• Make appropriate decisions and calls to carriers to maximize reimbursement on accounts to be worked.
• Correct all errors on electronic error reports using all available information.
• Meet current production, utilization and quality standards.
• Participates in trainings/meetings with Payers, internal departments, offshore partners, Client contact(s) and TES Management, etc. to address trends in denials or unprocessed claims
• Assists in identifying current and/or potential billing issues specific to outstanding receivable
• Presenting data to appropriate parties and partnering to develop resolutions
• Participates in daily production assignments that will continue to develop understanding and knowledge of processing guidelines and expectations of respective client(s) payer mix
• Ability to take patient phone calls and assist Customer Service when business needs arise
• Review and analyze claim denials in order to perform the appropriate appeals necessary for reimbursement.
• Receives denied claims and researches appropriate appeal steps.
