The Accounts Receivable Retro Adjudication Specialist II is responsible resolving all transactions held for retro adjudication review, ensure claims are billed accordingly based on payer claim policies and/or bill the next responsible party. Responsibilities include validating patient’s insurance coverage, updating claims/accounts accurately and contacting patients, account guarantor and/or insurance carriers.
- Through an assigned work queues, the Accounts Receivable Retro Adjudication Specialist II will follow protocols to determine best course of action to follow up on open receivables.
- Applies strong technical knowledge of all aspects of billing and collections including billing policies, regulations, diagnosis and procedure coding, and applicable to determine resolution.
- Performs demographic and insurance coverage updates on account as appropriate and bill new insurance as appropriate.
- Contacts insurance companies and/or patient/guarantor through phone contact, correspondence, online portals and other approved means to obtain status of outstanding claims and submitted appeals.
- Reviews account history for continuous follow up.
- Addresses incoming correspondence and respond timely to ensure prompt resolution. Prepares correspondence to insurance companies, patient and/or guarantor, as necessary.
- Documents clearly in billing system the claim issue and course of action taken on every account worked. Documentation and action must be clearly noted for future follow up and review.
- Escalates issues and problems to Supervisor as appropriate.
- Identifies trends or pattern of persistent problems.
- Performs charge corrections based on payer and institutional policies.
- Performs other job duties as required and assigned, but not limited to job functions within the area of accounts receivable follow up.
Conforms to all applicable HIPAA, Billing Compliance and safety policies and guidelines.
- High school graduate or GED certificate is required.
- A minimum of 2 years’ experience in a physician billing or third party payor environment.
- Candidate must demonstrate a strong customer service and patient focused orientation and the ability to understand and communicate insurance benefits explanations, exclusions, denials, and the payer adjudication process.
- Must demonstrate effective communication skills both verbally and written.
- Ability to multi-task, prioritize, and manage time effectively.
- Functional proficiency in computer software skills (e.g. Microsoft Word, Excel and Outlook, E-mail, etc.)
- Ability to work independently and be a team player.
The ideal candidate is a motivated individual with a positive attitude and exceptional work ethic.