Triage & Order Quality Specialist I

SUMMARY

The Triage & Order Quality Specialist is responsible for accepting, entering, identifying deficiencies and resolving those for the daily orders that enter our systems. Active and proactive auditing of completeness and quality of the order details for each request including all required demographics, clinical data and financial responsibility information. This role will assist directly and indirectly in collecting missing information and sourcing correct information when necessary. This role has high standards for compliance and must follow all HIPAA and Compliance protocols without issue.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following:

• The Triage & Order Quality Specialist supports Prometheus Labs and all order- to- cash processes within the Revenue Cycle areas to ensure that reportable commercial orders are billable and all effort is made to resolve deficiencies and drive collectability.
• Reviewing all reimbursement related orders, identifying deficiencies and resolving those for the daily orders that enter our systems.
• Submit and follow-up on prior/retro-authorizations.
• Active and proactive auditing of completeness and quality of the order details for each request including all required demographics, clinical data, CLIA and Billing requirements.
• Proficient in researching missing or erroneous information on accounts using various portals and other resources; including outreach and identification of unknown payors.
• Proficient in analyzing, researching claim issues applying federal, state, payor rules and procedures.
• This role has high standards for compliance and must follow all HIPAA and Compliance protocols without issue.
• Ability to work in a team environment and adapt to changing workloads and new information.
• Provide World Class customer experience and ultimate order support behaviors when working with providers, patients and payors.
• Stay current with relevant guidelines and policies for the CLIA lab processing, billing and collections performed internally and externally by vendors and contractors.
• Maintain strictest confidentiality; and adhere to all HIPAA guidelines/regulations.
• Quality monitoring and escalations for exceptions
• Support all documentation standards and report deviances.
• Meet or exceed daily performance standards for productivity and quality.
• Perform other duties as required.

SUPERVISORY RESPONSIBILITIES

This job has no supervisory responsibilities.

QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Required Qualifications:

• Associates degree in Business, Analytics, Healthcare, or related field; or High School Degree/General Education Diploma and 3 years of relevant experience in lieu of Associates degree.
• 2+ years of experience in medical data entry, eligibility and benefits verification, revenue cycle, quality audits in a laboratory setting or Med Device a plus.
• 2+ years of experience in professional medical billing, claims, and insurance processing.
• Solid understanding of healthcare industry, Laboratory or ancillary services order entry, clinical data entry, medical coding, claim process and US payor/ Insurance structure. Working knowledge of government, managed care, and commercial insurances, claim submission requirements, reimbursement guidelines, and denial reason codes.
• Strong knowledge of electronic eligibility transactions, EHR operating systems involving investigation and correction of accounts; including updates to patient demographics, financial, and guarantor information.
• Proficiency in Microsoft Office applications.
• Proficient computer skills to include Internet navigation, payor portal functionality and excellent attention to detail.
• Ability to work quickly and accurately and meet timelines and volume pressures.
• Demonstrated ability to perform the essential duties of the position with or without accommodation.

Preferred Qualifications:

• 3+ years of experience in medical or insurance billing field.
• 3+ years of experience in data entry, eligibility and benefits verifications, revenue cycle, or quality audits.
• Experience with Xifin applications.
• Medical billing certification.
• Knowledge of medical coding; including (ICD-10), Coding Procedure Terminology (CPT), and HCPCS coding.
• Understanding of ASC X12 (ANSI) claims adjustment and remark codes and plan benefits.

LANGUAGE/COMMUNICATION SKILLS

Proven and effective interpersonal communication skills with a demonstrated ability to interact with customers and colleagues in a positive, friendly, and professional manner. Excellent communication skills.

MATHEMATICAL SKILLS

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.

REASONING ABILITY

Ability to evaluate situations, analyze information logically, and draw sound conclusions based on facts. Critical thinking skills will be required to identify patterns, solve problems, and make informed decisions.

CERTIFICATES, LICENSES, REGISTRATIONS

None required.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit for extended periods of time in front of a computer monitor. The employee is required to use headphones for extended periods of time while handling phone calls. The employee is required to perform extensive data entry. The employee frequently is required to use hands to finger, handle, or feel and talk or hear. The employee is occasionally required to stand, walk, and reach with hands and arms. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision and ability to adjust focus.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually quiet.

All qualified applicants are considered for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability, veteran status or other protected class.