Insurance Svcs Rep

In 2020, united in a fierce commitment to deliver the highest quality care and exceptional patient experience, Virginia Mason and CHI Franciscan Health came together as natural partners to build a new health system centered around the patient: Virginia Mason Franciscan Health. Our combined system builds upon the scale and expertise of our nearly 300 sites of care, including 11 hospitals and nearly 5,000 physicians and providers. Together, we are empowered to make an even greater impact on the health and well-being of our communities. 

CHI Franciscan and Virginia Mason are now united to build the future of patient-centered care across the Pacific Northwest. That means a seamlessly connected system offering quality care close to home. From basic health needs to the most complex, highly specialized care, our patients can count on us to meet their needs with convenient access to the region’s most prestigious experts and innovative treatments and technologies.  

Franciscan Medical Group, as part of Virginia Mason Franciscan Health, is currently looking for a full-time Insurance Services Rep for the Franciscan Regional Billing Office in Tacoma. Five days a week with flexible start times and no weekends or major holidays required.

Job Summary:

This job is responsible for addressing, resolving and resubmitting outstanding insurance balances and routine denials that typically involve researching authorization and/or insurance eligibility in accordance with established standards, guidelines and regulatory requirements.  An incumbent works with both commercial and government health insurance payers to resolve payment issues on accounts through investigation and evaluation of patient account information, medical records, claims, Explanation of Benefits (EOB’s), reimbursement regulations and communication with third party payers.  Work involves removing barriers to processing claims by calling the payer, working on-line systems when appropriate, rebilling insurance via fax, electronic or hard copy, transferring payments or adjusting accounts per FMG procedures for writing off balances and applying adjustments.  Work also involves significant attention to detail in reviewing insurance remittance documentation, researching routine denial reasons and gaining experience in resolving issues through the appeal process.   

An incumbent gains experience in working with a wide variety of CPT codes associated with multiple specialties as well as broader knowledge of denial/reason codes and the ability to apply proactive critical thinking and troubleshooting skills to handle denials and resolution of issues that potentially impact revenue and customer satisfaction.  

Work requires some knowledge of insurance follow-up processes for government and non-government payers, insurance authorization/eligibility processes and privacy/confidentiality practices, as well as knowledge of medical terminology and insurance payer requirements.  An incumbent follows proper channels of communication in handling routine problems and recognizing issues to be escalated in accordance with established procedures.  Strong customer service skills and the ability to produce work with a high degree of accuracy/timeliness while meeting productivity standards are also required.

Essential Duties:

• Researches and resolves, within scope of position, rejected, incorrectly paid and/or denied claims within the established time frame; retrieves account data and references available resources to identify reasons for payment discrepancies and to quickly resolve outstanding claims in order to maximize appropriate revenue. 
• Accesses work queue to review claim/account status and to determine next steps/specific tasks to assure that accounts are properly reimbursed and to resolve payment issues.
• Understands and interprets insurance EOBs, knowing when and how to assure that maximum payment has been received; gains experience in accurately deciphering denial reasons and in planning follow-up steps.
• Contacts insurance companies, payers and/or other stakeholders to gather all necessary information; resolves issues (within scope of position) and facilitates/expedites prompt payment of claims; reopens claims as necessary to facilitate maximum reimbursement from insurance companies.
• Communicates effectively over the phone and through written correspondence to explain why a balance is outstanding, denied and/or underpaid using accurate and supported reasoning based on EOBs, reimbursement, and payer specific requirements.
• Resubmits claims (in hardcopy or electronic format) as requested to include all appropriate information. 
• Enters appropriate corrections in the practice management system to assure appropriate reimbursement is received for all FMG providers.
• Recognizes when additional assistance is needed to resolve insurance balances and escalates appropriately and timely through defined communication and escalation channels.
• Resolves work queues according to the prescribed priority and/or per the direction of management and in accordance with policies, procedures and other job aides.
• Organizes open accounts by denial type or payer to quickly address in bulk with representatives over the phone, via spreadsheet, utilizing an on-line payer portal, etc.
• Documents all activities and findings in accordance with established policies and procedures; assures the integrity of all account documentation; maintains confidentiality of medical records. 
• Accurately documents patient accounts of all actions taken in billing system.
• Documents clear and concise notes within Epic according to established standards to facilitate resolution of outstanding claims/issues and assure that other staff are able to understand the claim history.
• Meets quality assurance and productivity standards for timely and accurate denial resolution in accordance with organizational policies and procedures. 
• Gains and maintains current knowledge of internal, industry, and government regulations as applicable to assigned function. 
• Follows all department policies and procedures, desk level procedures, guidance documents, or other work tools designed to ensure accuracy, especially those requiring use of appropriate payment or adjustment codes.
• Gains understanding of detailed billing requirements, denial reason codes, and insurance follow-up practices; gains advanced understanding of government and commercial insurance reimbursement terms, payment policies and appropriate reimbursement amounts.
• Establishes and maintains professional and effective relationships with peers and other stakeholders.
• Works collaboratively with payers and revenue cycle staff to explain denial or underpayment issues.
• Establishes and maintains a professional relationship with clinics and FMG staff in order to research and/or resolve issues.
• Performs related duties as required.

Education/Experience:

One year of revenue cycle or related work experience that demonstrates attainment of the requisite job knowledge and abilities. Graduation from a post-high school program in medical billing or other business-related field is preferred.