General Position Description:
Claims supervisor performs management oversight of the claims processing department. This position includes oversight of; all claims processing, batching and posting of electronic and manual claims files, and posting payments. Needs a high level of analytical and data entry concepts and methods. Has an understanding of accounting principles for balancing and reconciliation purposes. This job requires a comprehensive knowledge of claims processing and reimbursement methodologies. This position provides supervision and oversight of all claims staff and claims activities for the agency. Individuals in this role should have a high level of understanding of; complex claims and reimbursement work involving the interpretation of detailed materials and instructions containing considerable quantitative data; maintain or check financial reports; prepare and batch claims files; monitor and follow-up on open receivables; perform billing services requiring specialized knowledge of third party payment sources. Individuals in this role are expected to have an in depth knowledge of solving routine claims and reimbursement problems for the claims department. This position has a high degree of both internal and external contact in responding to and initiating inquiries regarding claims and other related duties as required.
Performance Expectations and Competencies
1. Supervision of the claims adjudication process including preparation of electronic(837P) files, manual claims transactions, batching and transfer of claims files to payers, and posting electronic and manual payments to claims and client accounts as required or needed.
2. Reviews billing systems and documents to assure program compliance for Medicare, Medicaid, State funded, and insurance programs; assures that all appropriate supporting documentation is submitted with the billing
3. Ensures that all payers are billed in accordance with federal and state regulations. Ensures that secondary/tertiary/crossover claims are processed when appropriate.
4. Oversight of billing of 1st party payers (consumer billing). Creates statements and bills monthly for outstanding accounts receivables.
5. Reviews and updates codes and fees as needed or required. Reviews sliding fee scales annually and recommends updates based on the Federal poverty scale.
6. Account reconciliation including oversight of denial research and claims follow up. .
7. Maintains information or operational records; screens reports for completeness and arithmetical accuracy. Compiles lists, abstracts, and routine reports from a variety of sources including but not limited to:
Aged Receivables report
Census/Billed reports for all service areas
Quality indicators/Claims dashboards – Claims volume, approval rates, denial rates, payer mix, etc.
Claims Revenue/Accounts Receivables
Claims Reporting (as requested)
8. Monitors pre-claim exceptions for accuracy.
9. Primary responsible for providing training of staff on reimbursement procedures for the agency.
10. Serves on the Compliance and Operations Committees for the agency.
11. Completes other duties as assigned by supervisor
General Knowledge, Skills, and Abilities Required for Position
• Diagnostic Coding including International Classification of Diseases – Volume 10 (ICD-10).
• Procedural Coding for outpatient settings including Current Procedure Terminology (CPT-4) and Healthcare Common Procedure Coding Systems (HCPCS).
• Confidentiality rules and application for SU/MH consumers.
• HIPAA transaction sets with relation to 837 professional billing files.
• Health care third party reimbursement requirements for payers such as Medicare, Medicaid, State Funders, or private insurance
• Reimbursement practices of 1st and 3rd party billing and reimbursement, accounts receivable, and collection methodologies
• High level of communication and customer service skills to work with internal and external customers
• Intermediate skill level in Microsoft products applications
• High skill level for detail and analytical work
• Knowledge of eligibility and enrollment processes, authorization processes, and filing processes for payers
• Skilled in computer data entry and abstracting.
• Basic math
• Basic accounting skills
• Prepare financial reports and maintain ledgers and journals using computer software
• Write and interpret program billing policies, procedures and billing regulations
• Work independently with minimal direct supervision; plan and organize work
• Supervise/Instruct office clerical work including operation of general office and technical equipment
• Understand and follow oral and written directions
• Read and interpret procedure manuals
• Input accurate data into various computer systems in a timely manner
• Maintain patient confidentiality
• Work in an electronic environment
• Use 10-key adding machine or calculator
• Adjust to changes in workflow and meeting deadlines
• Flexibility and willingness to cross train for other coverage needs
• Communicate effectively electronically, orally, and in writing
Preferred and Minimum Position Qualifications
• High School Diploma or GED required.
• Associates Degree/Certificate in Medical Billing/Coding preferred.
• Medical Billing/Coding certifications/credentials or experience preferred The combination/equivalency of:
5 years claims experience performing claims adjudication processes or medical accounts receivable functions and/or 3 years claims adjudication experience with at least 2 of the years being supervisory experience.
• Any combination of experience/education equivalent to meet the necessary job requirements may be considered.
Additional Job Requirements (Licenses, Certifications, Personal Vehicle, etc.)
• Reliable Transportation
• Must live within 2 hours of the agency