The Claims Processor - Follow-up's/Denials - PB Epic position is responsible for accurate and timely billing of hospital and Rural Health Clinic (RHC) claims to insurance payers. This role focuses heavily on denial management, claim follow-up, and reimbursement optimization while ensuring compliance with payer contracts, federal regulations, and internal policies.
Key Responsibilities
Billing & Claims Submission
- Prepare, review, and submit hospital and RHC claims to commercial insurance carriers.
- Ensure correct use of CPT, HCPCS, ICD-10, revenue codes, modifiers, and RHC-specific billing requirements.
- Verify charges, units, dates of service, provider credentials, and place of service.
- Submit corrected, adjusted, and late charges as needed.
Denial Management
- Analyze and resolve billing denials, rejections, and underpayments.
- Identify root causes of denials (coding, authorization, eligibility, medical necessity, bundling, timely filing, etc.).
- Prepare and submit corrected claims and formal appeals with appropriate documentation.
- Track denial trends and recommend process improvements to reduce future denials.
Insurance Follow-Up
- Conduct timely follow-up with payers on unpaid, underpaid, or delayed claims.
- Communicate with insurance representatives to obtain claim status and resolution.
- Maintain detailed notes and documentation in the billing system for all follow-up activity.
- Meet productivity and follow-up benchmarks to ensure timely reimbursement.
Compliance & Collaboration
- Ensure compliance with payer guidelines, hospital policies, and RHC billing regulations.
- Work closely with coding, registration, authorization, and clinical staff to resolve billing issues.
- Stay current on payer policy updates and RHC billing changes.
Required Skills & Qualifications
- Knowledge of full-cycle RCM billing processes for acute-hospital and/or rural health clinics REQUIRED.
- Experience working with HB & PB Epic, with strong experience working with PB Epic REQUIRED.
- Strong experience with insurance billing and denial resolution.
- Proficiency in CPT, ICD-10-CM, HCPCS, and modifiers.
- Familiarity with payer portals and claim management systems.
- Strong analytical, organizational, and follow-up skills.
- Ability to manage high-volume workloads with attention to detail.
Business Support