Claims Processor II

About the Department

The Claims Processor, under continuing supervision, is responsible for processing electronic medical claims and ensuring seamless communication with external agencies. This role will also provide training and support to staff members on departmental processes and procedures as needed. Additionally, the Claims Processor works with the Credible Project Team and Director of Financial Services to drive process improvements and support accounts receivable reporting. The overall goal of this position is to efficiently manage claims processing and contribute to the optimization of financial services operations.

DISTINGUISHING CHARACTERISTICS: This position is not part of a job series.

Position Duties

This job description is intended to describe the general nature and level of work being performed. It is not intended to be an exhaustive list of all responsibilities and duties required.

• Processes electronic claims, ensuring accuracy and compliance with individual contract requirements, resulting in timely and successful reimbursement.
• Tracks and maintains treatment authorizations, coverage allowances and usage, and service reporting, ensuring seamless communication and accurate client records.
• Creates and transmits electronic files, including 837/835 transactions, to contracted organizations, maintaining data integrity and ensuring successful submission and retrieval.
• Generates deposit reports, ensuring accurate funding source information for client and 3rd party payments, and facilitating efficient financial processing.
• Research and recodes clinical services as needed, ensuring accurate coding and compliance with regulatory requirements, and resulting in reduced claims denials and improved reimbursement.
• Responds to claims denials, seeking timely resolution and minimizing revenue loss, through effective communication with clinicians, clients, and payers.
• Reviews and resolves cash application issues, collaborating with team members to identify root causes and implement solutions, resulting in improved accounts receivable management.
• Communicates with clients and clinicians, providing account status updates and resolving issues, ensuring timely payment and improved customer satisfaction.
• Analyzes aging reports, ensuring accounts are up-to-date, and calls are made to clients or sent to collection as needed, minimizing bad debt and improving cash flow.
• Collaborates with the Director of Financial Services to initiate debt write-offs, negotiate settlements, and oversee collection procedures, ensuring compliance with regulatory requirements and minimizing financial loss.
• Supports the Credible Project Team, providing training and assistance to clinical team members, and ensuring successful project implementation and outcomes.
• Ensures compliance with federal and local regulations for collection processes, adhering to the Fair Debt Collection Practices Act, resulting in reduced risk and improved regulatory adherence.
• Performs other duties as assigned.

Minimum Qualifications

REQUIRED QUALIFICATIONS: 

• High school diploma or GED.
• Two years of related experience including accounts receivable accounting, billing procedures, and collection techniques.

Any equivalent combination of education and experience that provides the necessary qualifications to successfully perform the duties of the position will be considered.

Preferred Education and Experience:   

• Associate degree in a related field.
• Experience in medical insurance and public assistance billing.
• Experience in health and human services.

Professional Licenses/Certifications: 

• None

Other Requirements: 

• Bilingual in English and Spanish, with fluency in speaking and writing preferred.

Other Qualifications

 WORKING CONDITIONS AND ENVIRONMENT:

• Work is primarily performed in a typical office environment. 

PHYSICAL REQUIREMENTS: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Sits for long periods of time and walking and/or standing is only required occasionally.
• Views computer screens and utilizes a keyboard for prolonged periods of time.

Union Representation:

This position is represented by the Grant County Public Employees' Association (GCPEA) and a member of the Admin Services Bargaining Unit.