Claims Processor

SCCMHA JOB VACANCY ANNOUNCEMENT

CLASSIFICATION: Claims Processor

PAY GRADE: $21.85 - $25.69 Hourly

POSITION SUMMARY:

Under the general supervision of the Chief of Network Business Operations, this position will have the primary responsibility of processing provider network and hospital claims for payment. This position requires claims coordination of benefits (COB) experience ensuring all third-party insurance carriers have been appropriately billed prior to Saginaw County Community Mental Health Authority (SCCMHA) claims payment. The tasks of this position have monthly claims batch payment deadlines, which are coordinated with the other staff within the accounting department. This position must maintain current knowledge of regulations pertaining to approved CPT/HCPCS and Revenue Codes, methods of billing, and procedures related to Medicaid/Medicare and various unique Commercial Insurance reimbursements rules. This position will be knowledgeable about and actively support culturally competent recovery based practices; person centered planning as a shared decision making process with the individual, who defines his/her life goals and is assisted in developing a unique path toward those goals; and a trauma informed culture of safety to aid consumer in the recovery process.

ESSENTIAL DUTIES AND RESPONSIBLITIES:

1. Coordinate and adjudicate paper and electronic claims submitted by the provider network and hospitals for payment in accordance with policies and procedures. Approve clean claims for payment. Assist as applicable with denied claims. Submit overrides for approval when appropriate.

2. Verify authorizations as they pertain to proper coding, dating, and fund source.

3. Review coordination of benefits documents prior to claims payment. Verify the Explanation of Benefits submitted by the Provider matches the Coordination of Benefits information on file for the consumer. Ensure reason codes are reasonable. Follow-up with provider as necessary to resolve discrepancies.

4. Process Event Verification settlements following Network Service Auditing review.

5. Process retro payments when contracted rates are modified.

6. Verify all the backup for each provider check/EFT is an agreement prior to mailing the payment.

7. Research, compile and prepare claim(s) remittance reports and other statistical data. Reconcile provider explanation of benefits (EOB) back to the claims detail. Interpret provider contract rates and requirements as they pertain to claims payment and provider benefit packages.

8. Help to establish and implement ongoing improvements to procedures for claims processing.

9. Answer telephones/work with providers to obtain timely, accurate and complete claims data. Train providers or other staff when needed of proper SCCMHA claims processing requirements.

10. Enter daily CTN/CTS skill build SALs into Sentri based on daily attendance calendars submitted by the respective programs. Reconcile the SALs to the CTN/CTS attendance sheets.

11. Process consumer Ability to Pay (ATP) based upon CFIS documents. Enter consumer ATP’s data into Sentri. Perform insurance verification as applicable.

12. Provide backup and other miscellaneous duties as assigned.

13. Adheres to the mission, vision, core values and operating principles of SCCMHA at all times.

INCIDENTAL DUTIES AND RESPONSIBILITES:

1. Communicates well with consumers, co-workers, and supervisors and meets deadlines and follows through with others as promised in order to provide additional information and/or to answer questions.

2. Demonstrates the ability to provide exceptional customer service to all consumers, staff, and providers of service.

3. Obtains necessary computer training in order to stay current with system changes as needed to complete all tasks related to this position. Works independently to stay informed of changes made within the assigned service area.

4. Attends meetings, in-service training, etc, as required for the finance department, the assigned service area or the Authority.

5. Reacts productively and responsively to change and handles other essential tasks as assigned.

6. Insures that the front desk is covered at all times in order to provide necessary customer service.

(The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all duties and responsibilities required of personnel so classified.)

REPORTING RELATIONSHIPS:

Reports to: Chief of Network Business Operations

Supervises: None

WORKING CONDITIONS/ENVIRONMENT:

Works in office environment with usual pressures of time constraints and stress of long periods of computer use. Performs daily data entry of confidential financial data for individuals suffering from mentally ill or developmentally disabled.

QUALIFICATIONS:

Education: Associate Degree with healthcare related courses required. Medical terminology and medical billing college level courses required.

Experience: Three (3) years of healthcare claims processing (including coordination of benefits) experience required.

Licenses and Certifications: Valid Michigan Driver’s license with a good driving record.

Knowledge, Skills, and Abilities:

1. Professional knowledge of and ability to use computerized accounting software such as Great Plains.

2. Proficiency in Microsoft Office including Word, Excel, Access, and Outlook.

3. Comprehensive knowledge of the billing processing working with an Electronic Medical Records Healthcare System.

4. Knowledge of medical terminology and medical procedures associated with clinical billing codes.

5. Ability to communicate well with others and occasionally deal with irate individuals.

6. High degree of attention to detail.

7. Ability to diplomatically associate and relate to individuals of all social, economical, and cultural backgrounds.

8. Must be skilled in normal office procedures such as written and verbal correspondence and use of calculator and other office machines.

9. Maintaining a current knowledge of regulatory policies, procedures, and reporting will be required.

Physical/Mental Requirements:

1. Hearing acuity to converse in person and on telephone.

2. Visual Acuity to read and proofread documents and use CRT.

3. Ability to walk, stand or sit for extended periods of time.

4. Manual dexterity to write and to operate standard office equipment (PC, Keyboard, Copy Machine, Fax Machine, etc.)

5. Ability to lift and carry files and supplies at least 20 pounds.

6. Strong interpersonal skills to interact with leadership, employees, consumers and the general public.

7. Mental capacity to think independently, follow instruction and use judgment.

8. Analytical skills necessary to conduct research, analyze, and interpret complex data and identify and solve problems by proposing courses of action.

9. Ability to plan short and long range and to manage and schedule time.

10. Ability to handle stress in meeting deadlines and dealing with large numbers of employees and/or consumers.

(Listed qualifications are for guidance in filling this position. Any combination of education and experience that provides the necessary knowledge, skills, and abilities will be considered; however, mandatory licensing or certification requirements cannot be waived. Physical/mental requirements cannot be waived unless specifically indicated.)