Covenant Health

EDI Representative II 

Full-Time, 80 Hours Per Pay Period, Day Shift

Covenant Health Overview:

Covenant Health is the region’s top-performing healthcare network with 10 hospitals, outpatient and specialty services, and Covenant Medical Group, our area’s fastest-growing physician practice division. Headquartered in Knoxville, Covenant Health is a community-owned integrated healthcare delivery system and the area’s largest employer. Our more than 11,000 employees, volunteers, and 1,500 affiliated physicians are dedicated to improving the quality of life for the more than two million patients and families we serve every year. Covenant Health is the only healthcare system in East Tennessee to be named a Forbes “Best Employer” seven times. 

Position Summary: 

Responsible for working Electronic Data Interchange (EDI) rejected or denied medical claims at the Claims Acknowledgment Level. The EDI Representative conducts research to resolve the issue with the rejected and/or denied claims that were processed through the electronic medical claims’ files.  Basic knowledge of the billing requirements for UB and 1500 claims for facilities and professional services. Researches and verifies incorrect policy numbers, eligibility for patients, missing or incorrect data on claim forms such as invalid NPI, Taxonomy, payer id and working UHC smart edits.

Analyzes claim rejections and/or denials from payer’s clearinghouse with a variety of different issues, such as invalid member number, not eligible for benefits, physician’s NPI, invalid hcpcs/cpt codes, modifiers, charging units, and invalid payer ID to identify and correct.  If necessary, send to appropriate biller for further correction. Verifies and updates patient demographic and insurance eligibility information with complete and accurate information in patient account system to ensure timely rebilling. Basic knowledge of registration information including insurance verification, and Medicare Secondary Payer (MSP) requirements to resolve patient financial system claim issues. Demonstrates the ability to perform research on various systems, including Medicare, Insurance Carriers and State systems, to cross-check patient’s eligibility, authorization numbers with the payers and contact payers for additional information.

Prefer 3 or more years of experience in healthcare revenue cycle (i.e., medical billing, insurance verification, registration, insurance follow-up etc.). 

Recruiter: Kathleen Rice || kkarnes@covhlth.com || 865-374-5386

• Assists Billing Supervisor to recognize and identify issues pertaining to the working of accounts.
• Demonstrates the ability to handle varying tasks as well as understanding and interpreting procedures relative to the revenue process.
• Demonstrates knowledge of State and Federal regulations, HIPAA guidelines, HCFA guidelines, TennCare guidelines and other Third Party Payer requirements assuring departmental compliance.
• Recognizes situations, which necessitate supervision and guidance, seeks appropriate resources.
• Demonstrates an ability to understand the payer requirements of insurance carriers.
• Demonstrates an understanding of all patient information from the facilities and the specifics of each follow-up to ensure appropriate reimbursement is received.
• Professionally deals with patients/public, co-workers, physicians, facilities, agencies and/or their offices, and other facility personnel using verbal, nonverbal and written communication skills.
• Performs specific functions relating to billing of patient accounts.
• Consults and works collaboratively with Supervisors, Co-Workers, Department management, and other facility personnel, effectively performing tasks of position.
• Attends meetings as required and participates on committees as directed.
• Perform other duties as assigned or requested.
• Promotes good public relations for the department ad the facilities, adhering to desired behaviors.
• Participates freely in intradepartmental quality improvement activities whenever called upon to do so.
• Demonstrates promptness in reporting for and completing work, ensuring follow-through on assigned tasks.
• Demonstrates initiative in increasing skills and attends training programs as available.
• Utilizes resources available appropriately, i.e. use of equipment and supplies.
• Supports, models and adheres to the desired behaviors of the KBOS Constitution for using the community’s resources wisely which are; be aware of cost and quality when making spending decisions, demonstrate a personal commitment to reduce waste, consider the impact on other departments and facilities within Covenant health when making decisions or taking action and ensure that meetings lead to solutions.