Job Description

Category:
Administrative/ Clerical

Facility:
SMG - Boston/Brighton Area - Revenue Mgmt.

Department:
PPSC Billing Center Admin

Req Number:
53900

Job Details:

Steward Health Care System LLC ("Steward") is a fully integrated, physician-led national health care services organization committed to providing the highest quality of care in the most cost-efficient manner in the communities where our patients live. Steward - the largest privately held health care company in the U.S. - owns and operates 35 community hospitals across nine states, serves over 1,000 distinct communities and employs approximately 40,000 health care professionals. In addition to our hospitals, the Steward provider network includes 4,800 providers, 25 urgent care centers, 87 preferred skilled nursing facilities, substantial behavioral health offerings, over 7,300 hospital beds under management, and approximately 1.5 million full risk covered lives through the company's managed care and health insurance services.

Steward Medical Group (SMG), Inc. is Steward's multi-specialty group practice with over 4,500 employees including over 1,800 physicians and advanced practitioners. SMG operates approximately 450 practice locations throughout Massachusetts, Southern New Hampshire, Rhode Island, New Jersey, Pennsylvania, Ohio, Florida, Utah, Arizona, Texas, Louisiana and Arkansas, and provides more than 4 million patient encounters per year.

Summary:
Under the direction of the Manager, Payor Intelligence, the Claims Reimbursement Specialists responsible for review of managed care contracts against healthcare claims to identify underpayments. This role will work with payors to resolve underpayments and provide feedback to other Steward Health Care departments regarding identified opportunities for maximizing contractual reimbursements, claims payment root cause identification and resolution, and ensure proper reimbursement according to contracts, fee schedules/rate sheets.

Responsibilities:
* Reviews insurance contracts to gain thorough understanding of payment methodologies.
* Reviews payer rules, regulations and guidelines to ensure ethical and compliant standards
* Analyzes claims and calculates reimbursements based on contract terms to determine accuracy of payment through use of various systems, reports, and supporting documentation.
* Contacts insurance companies to obtain missing information, explain and resolve underpayments, and arrange for payment or adjustment processing.
* Researches and compares third party refund requests to the contract to determine appropriateness.
* Submits and/or documents refund information in the financial system for all appropriate accounts.
* Documents and communicates trends to the Manager and makes recommendations of possible solutions.
* Prepares and submits correspondence such as letters, emails, faxes, online inquiries, appeals, adjustments, reports, and payment posting.
* Maintains regular contact and provides information to necessary parties regarding claims status including payors, managers, and other SHCN and SMG internal departments.
* Build strong, lasting relationships with payors.
* Adhere to the HIPAA guidelines regarding confidentiality relating to the release of financial and medical information.
* Additional duties as assigned by Manager

Knowledge/Skills:
* Ability to perform mathematical calculations
* Must have knowledge of ICD-10 ,CPT-4 and HCPC coding
* Strong knowledge on third party payors guidelines and procedures
* Customer / Client Account Services Skills
* Successfully drives results while balancing multiple priorities and tasks
* Attention to detail.
* Possess strong verbal and written communication skills
* Possess strong analytical skills and computer skills; including Outlook, Excel and Word.

Education/Experience/Other:
* High school diploma or equivalent required
* Bachelor's degree preferred but not required
* 2-4 years health care claims processing, reimbursement, and payment follow-up background
* Prior experience with AthenaNet billing system is preferred, but not required
* Medical terminology.



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