Reimbursement Specialist

J  o  b    D  e  s  c  r  i  p  t  i  o  n

JOB INFORMATION

Effective Date:

11/1/2018

Entity:

Wisconsin

Job Code:

440060

Job Title:

Reimbursement Specialist

FLSA Exemption Status:

Non-Exempt

Management Level:

Individual Contributor

JOB SUMMARY

Under the general supervision of a Revenue Cycle Supervisor, the Reimbursement Specialist is responsible for a portfolio of accounts receivable and oversees the entire billing cycle from charge review, claims submission, and follow-up.  The employee is engaged in pro-active and independent collection of outstanding balances for specially handled UW Health accounts.

The position requires advanced knowledge of various program billing requirements as well as federal research billing rules, Medicare and Medicare, and/or Transplant Billing. The incumbent actively participates in internal audits and quality improvement initiatives, maintains documentation of current workflows, assists with special projects, and works closely with Research Compliance Department, the Office of Clinical Trials, IT, and Department Managers.  

The employee performs complex patient account follow-up activities, actively participates in quality improvement initiatives to improve accounts receivable and assists with special projects.  The Reimbursement Specialist is also responsible for answering questions regarding team functions, and the accurate and timely processing of appeals to various pertinent payers or programs.  

The Reimbursement Specialist will serve as the technical expert for complex workflows, providing ongoing updates and training to existing staff for their specific area of expertise. The specialist may be responsible for handling charge review edits, claim edits and preparation, insurance follow-up, denial resolution, and necessary follow-up to ensure accurate payment. 

This position represents UW Health and the Revenue Cycle team by adhering and upholding the UW Health Mission, Vision, and Values, and UW Health Service Performance Standards in providing the highest quality service. They will support their co-workers, engage in positive interactions, and provide helpful assistance in anticipating and responding to the needs of our customers.

ESSENTIAL DUTIES

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Core Responsibilities:

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Maintaining a complete portfolio of accounts receivable for area of expertise. This includes following accounts through the revenue cycle, from charge review, claim edits, claim submission, and follow up with third party payers and patients to facilitate prompt resolution of outstanding account balances. This includes:

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o Resolve claim edits via claim edit work queues and/or our external billing software

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o Review charges to ensure we are filing to correct guarantor (e.g. work comp, research, transplant, or personal/family)

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o Analyze and reconcile denied payment transactions.

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o Compile and file all information needed to appeal denials

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o Follow federal and state regulations to ensure compliance standards are met

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o Monitor timely filing requirements on claims and appeals

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o Follow-up with contracted payers to secure payments on outstanding balances

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o Evaluate third party payments to ensure accuracy relative to contract language (underpayment/overpayment)

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o Prepare specialized invoices and information as needed for each payor

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Verify patient coverage information and update registration as required

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Accurately document all actions taken to reconcile outstanding balances

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Communicate with Revenue Cycle teams, payors and others to resolve account problems; participate in meetings as needed to address any potential payor concerns

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Evaluate the payment status of outstanding third-party claims and resolve any impediments to payment by providing information such as appropriate medical records, detailed itemization of charges, information regarding other insurance benefits, and explanation of charges.

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Review and validate adjustments to accounts in the insurance portfolio based on insurance reimbursement, coverage, contracts and services provided.

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Review charges to ensure we are filing to correct guarantor (e.g. work comp vs. personal/family)

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Complete work on special projects, queries and reports as assigned

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Provide general assistance with team:

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o Complete quality improvement and productivity activities

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o Answer questions regarding team functions and assist with team direction

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o Assist in training staff as needed.

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Customer Service Standards:

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Support co-workers and engage in positive interactions.

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Communicate professionally and timely with internal and external customers

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Demonstrate friendliness by smiling and making eye contact when greeting all customers.

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Provide helpful assistance in anticipating and responding to the needs of our customers.

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Collaborate with customers in planning and decision making to result in optimal solutions.

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Ability to stay calm under pressure and deal effectively with difficult people

As needed, additional responsibilities reasonably within the scope of duties and physical requirements may be assigned.  ALL DUTIES AND REQUIREMENTS MUST BE PERFORMED CONSISTENT WITH THE UW HEALTH PERFORMANCE STANDARDS AND RESPECT FOR PEOPLE COMMITTMENTS.

X

Non-Clinical

JOB REQUIREMENTS

High School Diploma

or equivalent

Required

Associate's Degree

in Business, Finance, Health Information Management, or related field

Preferred

2 years

of experience in a healthcare revenue cycle or clinic operations role

Required

• Epic experience

• Three years of experience in a healthcare revenue cycle, specific to area of expertise (I.e. transplant, research, or client billing)

Preferred

LICENSE, CERTIFICATIONS, AND REGISTRATIONS MUST BE MAINTAINED PER UW HEALTH POLICY. 

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Advanced analytic ability

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Ability to make good judgments in demanding situations

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Ability to react to frequent changes in duties and volume of work

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Effective communication skills

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Ability to listen empathetically

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Ability to logically and accurately organize details

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Ability to manage multiple tasks with ease and efficiency

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Self-starter with a willingness to try new ideas

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Ability to work independently and be result oriented

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Positive, can-do attitude coupled with a sense of urgency

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Effective interpersonal skills, including the ability to promote teamwork

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Strong problem-solving skills

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Ability to ensure a high level of customer satisfaction including employees, patients, visitors, faculty, referring physicians and external stakeholders

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Ability to use various computer applications including EPIC

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Excellent PC operating skills (keyboard, mouse) and use of MS Office

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Broad knowledge of health care business office practices and principles

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Basic math skills and knowledge of general accounting principles

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Knowledge of medical and insurance terminology, CPT, ICD coding structures, and billing forms (UB, 1500)

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Maintain confidentiality of sensitive information

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Knowledge of Business Office policies and procedures

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Knowledge of local, state and federal healthcare regulations

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Knowledge of Microsoft Office

PHYSICAL REQUIREMENTS/WORKING CONDITIONS

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Sedentary: Ability to lift up to 10 pounds maximum and occasionally lifting and/or carrying such articles as dockets, ledgers and small tools. Although a sedentary job is defined as one, which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Up to 10#

Negligible

Negligible

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Light: Ability to lift up to 20 pounds maximum with frequent lifting and/or carrying of objects weighing up to 10 pounds. Even though the weight lifted may only be negligible amount, a job is in this category when it requires walking or standing to a significant degree.

up to 20#

Up to 10# or requires significant walking or standing or requires pushing/pulling of arm/leg controls.

Negligible or constant push/pull of items of negligible weight

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Medium: Ability to lift up to 50 pounds maximum with frequent lifting and/or carrying objects weighing up to 25 pounds.

20-50#

10-25#

Negligible-10#

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Heavy: Ability to lift up to 100 pounds maximum with frequent lifting and/or carrying objects weighing up to 50 pounds.

50-100#

25-50#

10-20#

☐

Very Heavy: Ability to lift over 100 pounds with frequent lifting and/or carrying objects weighing over 50 pounds.

Over 100#

Over 50#

Over 20#

Other - list any other physical requirements or bona fide occupational qualifications not indicated above:

Over 50 lbs.

UW Health does not require, nor does it expect that its employees lift more than 50 lbs unassisted. Objects in excess of 50 lbs should be lifted or moved with mechanical means or through a team lift. Employees in patient care areas are expected to utilize mechanical lifts and adhere to the "Use of Mechanical Lifts (Liko)" policy in the Patient Services Policy and Procedure Manual.

Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.

THE EMPLOYEE MUST BE ABLE TO COMPLETE ALL PHYSICAL REQUIREMENTS OF THE JOB WITH OR WITHOUT AN APPROVED ACCOMODATION. Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.