Clinical Claims Specialist - RN Preferred.
POSITION SUMMARY
The Clinical Claims Management Specialist will analyze reports to make sure all required documentation is accurate and complete and meets clinical state and federal requirement with claims processing. As a Clinical Claims Management Specialist (CCMS), you will be responsible for identifying lost revenue, the appropriate clinical requirements according to state/federal guideline under Home Health, collecting payments by obtaining signed orders, and implementing revenue cycle management strategies to minimize losses. Using Excel and other required platforms, data will be messaged and extracted to generate reports that help the Executive Director of Home Health Operations and branches. Extensive communication with physician offices and operations will be required. Will work with the Revenue Cycle Team to coordinate the clearing of inter-service messages in workflow, track claims data and submit claims for payment.
The Clinical Claims Management Specialist is exposed to all areas of our home healthcare business and are critical to the success of the branch. The data analyzed and reports generated are used to help run business more efficiently and effectively. Ability to generate accurate reports in a timely manner will help ensure that branch is meeting all its goals. Will assist with quality improvement initiatives from the data analysis perspective.
MINIMUM JOB REQUIREMENTS
Education & Qualifications:
Education: Bachelor's degree in nursing is preferred. Licensed Practical Nurse or Licensed Vocational Nurse experience is required.
Previous Experience: Proven ability to work successfully with office staff and field staff. Excellent customer service and interpersonal skills. Positive attitude with exceptional problem-solving skills and ability to analyze data. Excellent written and oral communication skills. Demonstrates a professional and caring approach. Well organizational skills and strong time management skills with the ability to prioritize daily workload. Goal and project-oriented individual.
Knowledge/Training: Active knowledge of clinical terminology preferred. Ability to establish and maintain strong working relationships with clinical staff and office staff is required. Understanding of Home Health state/federal billing requirements.
Computer Skills: Must be familiar with general use and functions of the computer, such as, usernames and password concepts; internet; e-mail; navigation of computer desktop or laptop, including starting programs, using files, and windows, effectively use navigation buttons and tool bars; ability to self-manage online HR services and online training programs. Proficiency in the use of a computer, Excel, Access, and ability to master in-house computer systems are required. Strong typing skills are preferred.
JOB SPECIFIC EXPECTATIONS
Branch Support:
Understands the clinical components of dropping home health billing claims and ensures requirements are in place.
Understands home health billing guidelines.
This position requires the ability to always handle stressful situations with calmness and courtesy.
Works on a wide variety of duties.
Interaction with various departments and personnel.
Works within a team environment.
Processes and responds to inter-service messages. Works with office and field staff to ensure that all messages are addressed in a timely manner.
Administrative Support:
Maintains accurate record keeping system to track all completed analyst duties.
Provides daily feedback to the of the status of outstanding work.
Works with AVP of Home Health Business Operations and Executive Director of Operations (EDO), to process claims daily and reduce Past Due Claims (PDU) before the Write Off phase.
Make and Take calls from physician offices and collect payments by obtaining signed orders and implementing revenue cycle management strategies to minimize losses.
Performs duties as assigned by the EDO or their designee.
Data and Reporting:
Utilize the Unbilled PDGM report to identify outstanding claims.
Utilize the Perform Billing Audit report to identify outstanding items holding private claims.
Utilize the Analytics AR reports to track and identify held claims.
Utilize order tracking report and World View reports to identify outstanding orders for follow up.
Physician Portal Management:
Promotes and presents the benefits of Physician Portal to physicians and other referral sources in the medical community; troubleshoots portal errors by contacting the Information Technology department.
Runs and interprets hand delivery physicians' orders reports to improve department outcomes.
Sends out weekly reports on physician portal enrollment, signature trends and hand delivery escalations to management.
Reporting:
Updates the physician databases accurately on a need to and ongoing basis.
Coordinates physician orders escalations for the Billing/Compliance department to meet billing and CMS deadlines.
Maintains the physician database user defined information tab; add new physicians to the database and inactivate physicians after conducting appropriate escalation.
Develops and maintains an escalation database for all physicians who fail to meet the 30-day signature requirement recommended by CMS.
COMPANY EXPECTATIONS
Values: Upholds and lives the Values of Visiting Nurse Health System:
Respect and Integrity
Excellence
Stewardship
Care
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