Claims Specialist

101 Rogers Memorial Hospital, Inc.; Town of Oconomowoc (WI); On-site; USD 42,000 - 62,000; Full time

Benefits offered by this job

Health, dental, and vision insurance

401(k) retirement plan

Life/disability insurance

Tuition reimbursement

Health and wellness program

Employee assistance program (EAP)

Job summary

Rogers Behavioral Health is seeking a Claims Specialist to manage follow-up with commercial and governmental payers, resolving billing issues and securing reimbursement in a timely manner. The role requires analyzing denials, identifying payer discrepancies, and communicating with payers and the hospital business office to improve cash flow and A/R metrics.

Strong knowledge of payer guidelines, coding basics, and HIPAA compliance is essential, with opportunities to participate in quality

Qualifications

• High school diploma or equivalent required.
• Minimum of one year of relevant experience in mental health or medical insurance billing and/or collections.
• Knowledge of third-party payer guidelines, reimbursement, follow-up, and collections.
• Familiarity with ICD-10, CPT, HCPCS coding and medical terminology.
• Effective communication, leadership, organizational, and problem-solving skills.
• Ability to manage multiple tasks and meet deadlines.

Responsibilities

• Examine denied and underpaid claims to determine discrepancies.
• Communicate with payers to follow up, resolve variances, and secure timely reimbursement.
• Identify root causes of denials and develop strategies to reduce A/R.
• Ensure compliance with HIPAA when handling patient information.
• Participate in quality improvement initiatives and report trends to management.
• Maintain professional conduct and effective communication with staff and payers.

Skills

Denials analysis

Payer follow-up

HIPAA compliance

Communication skills

Problem-solving

Education

High school diploma or equivalent

Tools

Microsoft Word

Excel

Outlook

Oracle Health Patient Accounting

Teams

OneNote

Job description

Summary: The Claims Specialist is responsible for following up directly with commercial and governmental payers to resolve billing issues and secure appropriate reimbursement in a timely manner. This individual identifies and analyzes denials and payment variances and enacts corrective measures as needed to effectively communicate and resolve payer errors.

Job Duties & Responsibilities

• Examines denied and underpaid claims to determine reasons for discrepancies
• Communicates directly with payers to follow up on outstanding claims, resolve payment variances, and achieve timely reimbursement
• Works with management to identify, trend, and address root causes of denials; helps pinpoint strategies for reducing A/R
• Maintains a thorough understanding of federal and state regulations, as well as specific payer requirements and explanations of benefits, to identify and report billing compliance issues and payer discrepancies
• Effectively handles all communications, including telephone and email, from payers and departments with the business office
• Participates in continuous quality improvement efforts on an ongoing basis, establishing goals with supervisors and tracking progress
• Demonstrates initiative and resourcefulness by making recommendations and communicating trends and issues to management
• Understand and maintains compliance with HIPAA guidelines when handling patient information
• Performs other duties as assigned
• Promote a team atmosphere by treating individuals with respect and honesty and by using direct communication and active listening skills
• Be open to change and actively support change
• Be open to others’ ideas and points of view
• Evaluate employees objectively and provide employees with periodic feedback
• Promote department goals as well as the mission of the hospital
• Communicate goals to fellow staff members
• Maintain department policies and procedures
• Include requirements and guidelines from external agencies (i.e., Joint Commission, State of Wisconsin)
• Maintain and/or communicate to appropriate party function backlog at a set time
• Educate new staff regarding regulations or requirements of those functions that relate to their areas or departments, as directed
• Demonstrate acceptance and training of student interns in the department, as directed
• Participate in hospital committees, performance improvement team meetings, and team projects, as directed
• Demonstrate punctuality and preparedness
• Demonstrate effective communication skills
• Demonstrate good organizational skills
• Contribute in a positive, solution-focused manner
• Conduct self in a professional manner
• Demonstrate organizational skills that promote timely response to all inquiries and to task completion
• Communicate with all individuals in a positive and professional manner
• Attempt to resolve individual issues with peers in a positive, calm manner, with a focus on solution
• Communicate concerns and provide solutions for same
• Project a professional image by wearing appropriate, professional attire
• Ability to influence departments within Rogers and provide technical guidance

Physical/Mental Demands

This role primarily involves sedentary work, requiring the employee to sit for extended periods. Occasional walking, standing, or reaching may be necessary to retrieve materials or operate office equipment. Lifting is moderate; must be capable of lifting a minimum of twenty (20) pounds. Reaching, handling, grasping and manual dexterity are necessary to operate various equipment. Verbal and hearing ability are required to interact with staff, consultants, patients and family members of patients. Numerical ability is required to maintain records and operate a computer. Tact is required to interact effectively with employees and professional staff. Logical thinking and discretion required to make decisions in initiating and implementing policies and procedures and standards. Must be able to read and communicate through written, verbal and auditory skills and abilities. Must be physically/mentally able to perform job duties as verified by a physical exam by a licensed physician, per post-employment physical.

Education/Training Requirements

• High school diploma or equivalent required
• Minimum of one year of relevant experience in mental health or medical insurance billing and/or collections required
• Demonstrated knowledge of and experience with third‑party payer guidelines, reimbursement, follow‑up, and collections
• Demonstrated knowledge of claims review and analysis; ICD‑10, CPT, and HCPCS coding; and medical terminology
• Effective communication, leadership, organizational, and problem‑solving skills
• Ability to manage multiple tasks and projects simultaneously
• Ability to analyze data, identify improvement, and implement change
• Strong interpersonal and customer service skills
• Proficiency with Microsoft Word, Excel, Outlook, Teams, OneNote and Oracle Health Patient Accounting systems
• Ability to work quickly and effectively in a fast‑paced detail‑oriented environment while adhering to deadlines

With a career at Rogers, you can look forward to a Total Rewards package of benefits, including:

• Health, dental, and vision insurance coverage for you and your family
• 401(k) retirement plan
• Employee share program
• Life/disability insurance
• Flex spending accounts
• Tuition reimbursement
• Health and wellness program
• Employee assistance program (EAP)

Through UnitedHealthcare, UMR and HealthSCOPE Benefits creates and publishes the Machine-Readable Files on behalf of Rogers Behavioral Health. To link to the Machine-Readable Files, please visit Transparency in Coverage (uhc.com)

ABOUT ROGERS BEHAVIORAL HEALTH:

Rogers Behavioral Health is a nationally recognized, not‑for‑profit provider of highly specialized psychiatric care. Rogers offers evidence‑based treatment for children, teens, and adults with OCD and anxiety, addiction, depression and other mood disorders, eating disorders, trauma, and PTSD. Backed by more than a century of experience, Rogers is leading the way on measurement-based care and use of clinical outcomes. Rogers provides residential care and has three inpatient facilities located in southeastern Wisconsin. Rogers also offers outpatient services in a growing network of communities across the U.S. The System also includes Rogers Behavioral Health Foundation which supports patient care, programs, and research; and Rogers InHealth an initiative that works to eliminate the stigma of mental health challenges. For more information, visit rogersbh.org.

EOE/MFDV Equal Employment Opportunity – Rogers Behavioral Health