The Refund Specialist is responsible for the accurate and timely resolution of self-pay and insurance credits. Thoroughly researches credit balances to determine if an overpayment occurred and initiates the refund process accordingly, outlining the reason for the refund and including explanation of benefits (EOBs), if needed.
Handles payer refund requests including validating the refund following review of the account history and submission of a refund request to Accounts Payable.
Partners with the Revenue Cycle Reconciliation Analyst, as needed, to research accounts and validate self-pay and insurance refunds.
Maintains a working knowledge of CPT-4 and ICD-10 coding principles, government, managed care and commercial payers, payment posting, ERA processing, claim adjustment reason codes, contractual adjustment, copays, coinsurance and deductibles.
Demonstrates the ability to be an effective team player. Upholds best practices in day to day processes and work flow standardization to drive maximum efficiencies across the team.
Reviews payer correspondence requesting refunds. Investigates the affected accounts included all payments applied to the account to determine if an over payment has occurred.
Processes refund requests and forwards to Accounts Payable.
Effectively communicates with Payment Specialists on credit trends related to Electronic Remittance Advice (ERA) processing to facilitate automated processing opportunities.
Partners with Reconciliation Analyst on complex accounts to ensure that a self-pay and / or insurance credit is an overpayment
Identifies root causes and credit trends and works with the Revenue Cycle leaders and Finance Department to mitigate additional credit account balances.
Effectively prioritizes work assignment / s and demonstrates flexibility in assuming self-pay and insurance credit to minimize lag days and ensure team goals / objectives are met.
Participates in regularly scheduled team meetings offering new paths, procedures and approaches to maximize opportunities for performance and process improvement
Receives and sorts all correspondence received via mail for the Primary Care Clinic Billing department.
Communicates specific reasons for non-payment to appropriate staff for follow up.
Takes appropriate actions to follow up on unidentified payments.
Identifies and processes charity applications as needed
Communicates with patients, insurance companies, doctors, lawyers, and other payers as needed.
Responds to patients and other third party telephone inquiries. Routes communications to appropriate personnel for further assistance as needed.
Performs secondary billing procedures after primary insurance is paid.
Reviews insurance remittances to ensure accurate payments; resubmits as necessary.
Advises patients of necessary actions and strategies for debt repayment including payment plans.
Maintains knowledge of the requirements and regulations of specific insurance carriers and corresponding insurance forms.
Recognizes coding problems and forwards them to coder with records for resolution.
Pursues professional development goals through continuing education and involvement as required.
Participates in work teams and departmental special projects as needed.
Checks explanation of benefits on account payments for either a write off or to be referred to another collector for secondary billing.
Submits corrected claims due to credit balances.
Maintains accurate productivity records in accordance with operating procedures.
Performs general office clerical work including, but not limited to, copying files, entering data and answering phones.
Attends and participates in department staff meetings.
Maintains patient confidentiality at all times.
Emergency duty may be required of the incumbent that includes working in special needs or Red Cross shelters or to perform other emergency duties including, but not limited to, responses to threats or disasters, man-made or natural.