Charge Capture Claim Edit Spec

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Work Shift

Day (United States of America)

Job Summary:

The Charge Capture Claim Edit Specialist 1 is responsible for reviewing clinical documentation to ensure timely accurate and compliant charge capture and processes paper and electronic claims to payers with full and complete information to satisfy and facilitate the claim for payment. The Charge Capture Claim Edit Specialist 1 works closely with Physician Practices as an educational resource to inform and educate departments on the latest government regulation and requirements including CMS the State and payer regulations related to these addition the Charge Capture Claim Edit Specialist 1 works payer acceptance/reject reports . The Charge Capture - Claim Edits Specialist 1 also collaborates with cross-campus counterpart(s) and Physician Practice to ensure clinical documentation in high risk areas is consistent and complete while also producing accurate and timely claims in order to prevent denials and maximize reimbursement The Charge Capture Claim Edit Specialist 1 collaborates with cross-campus counterpart(s) to ensure consistency in processes in such a manner that each individual can act as a back-up for the other to ensure seamless charge capture in high risk areas when one individual is out. Duties include charge entry ensuring correctness of coding in the CDM and clinical documentation and providing ongoing education to charging departments while also being responsible for working claim edits within the patient accounting system and claim scrubber edits prior to final submission.

Core Responsibilities and Essential Functions:

Job Functions* Ensure charging/documentation is accurate and complete both department to department and cross-campus* Assess physician and nursing documentation to ensure it supports the charge codes selected including supporting medical necessity* Review the clinical records on an ongoing basis to identify any overcharges undercharges or charges that necessitate an additional document to be justified* Analyze verify and work with departments to modify charging/documentation procedures for high risk areas such as infusion services* Develop and implement training required to educate Physician Practices on the changes updates and additions to the CDM related to high risk area(s) such as infusion services* Proactively identify and analyze new charging opportunities in coordination with assigned departments* Research and analyze charge and coding requirements for new services and technologies* Consistently meet the current productivity standards in ensuring accurate charge capture in high risk areas such as infusion services* Consistently meet the current quality standards in ensuring accurate charge capture in high risk areas in a timely manner* Meet productivity standards benchmarks targets and reporting requirements as assigned by the department Manager or Supervisor* Prepare all bills for assigned accounts in a complete and accurate manner for transmission to the appropriate payer source.* Enter all patient info into patient accounting system including patient demographics and insurance additions and changes. Verify insurance eligibility.* Audit and validate all charge capture information including CPT and ICD-9 codes.* Complete charge edit steps according to department policy including; compare demographic info between registration and billing systems. verify all codes admit dates referring physicians modifiers and review/respond to Provider correspondence.* Provide support to provider sites for resolving Charge Capture issues.* Analyze research and independently resolve claim submission edits by obtaining information from the medical record and applying CMS rules and regulations CPT coding guidelines and departmental policies and procedures.* Identify duplicate or missing charges and resolve working with clinical departments as necessary.* Ensure compliance with all state and federal billing regulations and report any suspected compliance issues to the billing supervisor.* Ensure all documentation is complete prior to claim submission.* Utilize and verify appropriate claim coding requirements following department guidelines and procedures for completing or correcting errors.* Effectively contact Workers Comp carrier and obtain insurance billing information in a timely manner.* Work all control reports to ensure timely and accurate claim submissions.* Work with utilization review staff and admitting staff to obtain or clarify authorization numbers for claims when appropriate.* Ensure claims are submitted in the proper format and to the correct destination as defined by the requirements in the facilitys various Third Party Payer contracts.* Resolve issues with payer sources reporting any ongoing problems to the appropriate Manager or Supervisor.* Upon notification by follow-up representatives or other staff add payer sources and bill them appropriately.* Ensure all billing activity on accounts is documented and explained in the appropriate fields in the patient accounting system.* Ensure all assigned accounts are billed to secondary insurances when appropriate.* Coordinate and keep in contact with various physician billing services to ensure proper billing documentation when necessary.* Consistently meet the current productivity standards in processing daily electronic and/or paper claims to payers.* Consistently meet the current quality standards in processing daily electronic and/or paper claims to payers.* Provide individual contribution to the overall team effort of achieving the department AR goal.* Identify opportunities for system and process improvement and submit to management.* Demonstrate proficient use of systems and execution of processes in all areas of responsibilities.* Demonstrate knowledge of WHS System HIPAA privacy standards and ensure compliance with system PHI privacy practices.* Follow the Health Systems general Policy and Procedures the Departments Policy and Procedures and the Emergency Preparedness Procedures.* Become cross-trained and fill in for other staff as assigned.* Follow department guidelines for lunch breaks requesting time off and shift assignments.* Operate office equipment and machinery and utilizes ergonomic workstations equipment and supplies.* Follow JC and outside regulatory agencies mandated rules and procedures.* Utilize assigned menus and pathways in the hospital mainframe system. Report software application problems to the appropriate supervisor.* Utilize assigned menus and pathways in foreign software applications. Report software application problems to the appropriate supervisor.* Utilize assigned computer hardware. Report hardware problems to the appropriate supervisor.* Participate in the testing for assigned software applications including verification of field integrity.* Perform other duties and responsibilities as Professional Development* Provide individual contribution to the overall team effort of achieving the department goal* Identify opportunities for system and process improvement and submit to management* Demonstrate proficient use of systems and execution of processes in all areas of responsibilities* Demonstrate knowledge of the health system HIPAA privacy standards and ensure compliance with system PHI privacy practices* Follow the health systems general Policy and Procedures the Departments Policy and Procedures and the Emergency Preparedness Procedures* Become cross-trained and fill in for other staff as assignedAdministrative Professional Communication* Assure patient privacy and confidentiality as appropriate or required* Ensure minors have a parent or guardian listed as guarantor as appropriate* Communicate in a professional manner with patients their families and representatives from third party payor organizations* Communicate in a professional manner with physicians physician staff co-workers management and clinical staff* Maintain professional relationships and convey relevant information to other members of the healthcare team within the facility and any applicable referral agencies* Initiate communication with peers about changes and procedures* Relay information appropriately over telephone email and other communication devices* Interact with internal customers including HIM Revenue Integrity Patient Access and the SBO in a professional manner to achieve revenue cycle department AR goals and objectivesDepartment Methods/Procedures/Operations* Follow department guidelines for lunch breaks requesting time off and shift assignments* Operate office equipment and machinery and utilizes ergonomic workstations equipment and supplies* Follow JCAHO and outside regulatory agencies mandated rules and procedures* Utilize assigned menus and pathways in the hospital mainframe system. Report software application problems to the appropriate supervisor* Utilize assigned computer hardware. Report hardware problems to the appropriate supervisor* Participate in the testing for assigned software applications including verification of field integrity* Perform other duties and responsibilities as assignedPerforms other duties as assignedComplies with all Wellstar Health System policies standards of work and code of conduct.

Required Minimum Education:

High school diplomaGED

Required Minimum License(s) and Certification(s):

All certifications are required upon hire unless otherwise stated.

Additional License(s) and Certification(s):

Required Minimum Experience:

Minimum 2 years Collection experience Required orMinimum 2 years experience with a Practice Management System or PC-based applications Required

Required Minimum Skills:

Basic Coding knowledgeBasic billing & collection knowledgeAbility to perform mathematical calculationsKeyboard by touchExcellent communication skills when dealing with patients families public co-workers and professional officesBasic knowledge of medical terminologyBasic experience and knowledge of PC applicationsDetail-oriented good organizational skills and ability to be self-directedAbility to learn quickly and meet continuous timelinesStrong time management skills managing multiple priorities and a heavy workload in a high-stress atmosphereDemonstrated flexibility to perform other tasks as needed in an active work environment with changing work needsHigh-level problem solving analytical and investigational skillsExcellent internal/external customer service skillsExcellent communication skills to include oral and written comprehension and expressionAbility and willingness to exhibit behaviors consistent with principles of excellent serviceAbility and willingness to demonstrate and maintain competency as required for job title and the unit/area(s) of assignmentAbility and willingness to exhibit behaviors consistent with standards of performance improvement and organizational values (e.g. efficiency & financial responsibility safety partnership & service teamwork compassion integrity and trust & respect)

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