Call Processing Reimbursement Specialist I (English/Spanish Bilingual Required)

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 well 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 demonstrate 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:

Bilingual English/Spanish required
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:

Sedentary work requires sitting and use of the PC most of the day

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.