Job description

Position Summary:
The Contract & File Maintenance Department is
looking for a Fee Schedule & Reimbursement Specialist who is responsible
for maintaining NextGen databases and peripheral programs. Proper documentation
and timely communication of ticket/project status’/needs and collaborating with
numerous departments to ensure timely resolution. Specialist will need to be
able to read, interpret, research, and calculate reimbursement rates.
Comfortable reaching out to payers and third party sources to obtain fee
schedules data.

Key Responsibilities:
•
Create, Maintain and Update Profiles in Practice Management Data Base System; Nextgen.
o Profiles; Payer, Group, Provider, Location, Contract, CPT, Service Item/Charge Master
•
Collect and maintain provider information, including education, licensure, certification, work history, etc.
•
Establish and maintain standardized documentation of system change history.
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Place, track and communicate claims on hold, and when approved to release
•
Troubleshoot & Escalate NextGen Claim Issues
•
Assist in billing payer issues involving provider participation and claim holds.
•
Work and Manage OS Ticketing System.
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Maintain Provider Supervision Linkage for Adequate Billing
•
Reporting and documenting discrepancies in system functionality.
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Create and maintain provider files and related documentation and process provider data changes and provider terminations in PM and Contracts database.
•
Creates new users/ resets passwords. Establish and maintain online payor portal access for all users.
•
Develop and maintain contract / fee schedule library of NextGen documents and data.
•
Performs CPT/HCPCS code and fee schedule updates, analyzing each new code for coverage, policy, reimbursement development, and implications for system edits.
•
Coordinates research and responds to inquiries on fee schedule discrepancies.
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Prepares correspondence to payers/insurances regarding coding and fee schedule updates.
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Works with provider contracting staff when new/modified reimbursement contracts are needed.
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Maintain provider contract linkage
•
Maintain, Analysis and Calculate and Charge Master Updates.
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Ensure that provider reimbursements and fee schedules are loaded in PM and contracts database in accordance with contractual agreements and that provider data is current.
•
Use Web Base Web Portals to download Fee Schedules
•
Ability to read, interpret, research, and calculate reimbursement rates for adequate Fee Schedule Reimbursement.
•
Review, Analysis and Report on Contract Analysis Reports to Identify Discrepancies and Update System with Findings.
•
Work & Maintain Relationship with outside vendors, third parties, payers/insurance companies.
•
Maintain provider data within Clearinghouse (Gateway/TriZetto) Web Based Data Base Systems {STEM}.
•
Maintain EDI & ERA Enrollment Data within Clearinghouse (Gateway/TriZetto) Web Based Data Base Systems {STEM}.
•
Support the enrollment process by initiating, monitoring, and maintaining enrollment requirements set forth by payers, payer intermediaries, and clearinghouses regarding electronic remittance advice (ERA).
•
Staying abreast of payer mergers and acquisitions impacting enrollment
•
Working with clearinghouse partners and third-party intermediaries to complete, submit, monitor, and maintain ERA enrollment activities
•
Support the enrollment process by initiating, monitoring, and maintaining enrollment requirements regarding electronic funds transfers (EFT).
•
Analyze and evaluate bank lockbox activity for direct EFT and ERA opportunities
•
Research and acquisition of supporting documentation, form completion, and signatures
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Identifying payers funding thru alternative payment methods (e.g. virtual credit cards) and convert to preferred ACH payment method.
•
Maintain a general understanding of payer electronic data interchange (EDI) requirements as it relates to claims adjudication
•
Maintains confidentiality of all information; adheres to all HIPAA guidelines/regulations.
•
Works collaboratively with peers and senior management to ensure business needs are being met.
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Preparing recommendations for process improvement opportunities.
•
Analyzes task creation & completion and presents results to department Director and other appropriate stakeholders.
•
Ready to jump in and help on RCM Special Projects.
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Perform any additional duties to be assigned from time to time.

Requirements:
•
Any combination of education and experience, which would provide an equivalent background.
•
Proficiency in Microsoft Word, Excel and SharePoint preferred.
o Excel: Knowledge and use of formulas (VLookup) and Pivot Tables.
•
Experience with CMS Guidelines
•
Time Management skills is essential.
•
Must possess strong research skills and perform well independently and in a team setting.
•
Experience with reviewing Contracts preferred.
•
Prior Knowledge of Fee Schedules preferred.
•
Ability to maintain a high level of confidentiality

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