This position adjudicates the daily/weekly/monthly procurement of outbound claims to health plans. As part of this role, steps are taken to assure that unbilled claims are moved into a billed status and those claims are both HIPAA-compliant and accurate, fairly representing the service provided by the organization.
This role also identifies routine errors on claim forms referring same to management for action.
Observes and assures that claims data from the host database passes correctly to the clearinghouse system(s) for transmission of the claim to the health plan.
Maintains appropriate data files in the clearinghouse system(s) so that claims can be procured by the clearinghouse system(s).
Maintains billing episode changes and/or similar account maintenance when health plan information is added, deleted or modified.
Maintains billable service override changes and/or similar account maintenance when health plan information is added, deleted or modified.
Prepares and maintains claim data for the organization's Audit Worksheet on a week to week basis per current method(s).
Prepares and maintain claims output for grant funding and other contracted coverage sources where a standardized 837 claim is not used.
Identifies and procures returned claims from the clearinghouse system(s), commonly known as "front-end rejections", where a claim was not further adjudicated by the health plan.
Prepares and processes secondary claims according to current method(s).
Participates in weekly conference calls with various markets or groups as needed.