Specialist, Billing

General Requirements/Job Duties:

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

Billing:

• Responsible for the evaluation, coordination, development and implementation of billing and related processes.

• Processes electronic and paper claims in a timely and accurate manner. Ensures edits to electronic claims meet and satisfy billing compliance guidelines for electronic submission. 

• Resolves clearinghouse and DDE claim errors and payer rejections.

• Performs follow-up processes on underpaid or unpaid insurance claims. Researches, identifies and rectifies any circumstances affecting delayed payment of accounts and takes steps to get claim paid utilizing websites, phone calls to the payers, and/or internal inquiry.

• Resolves issues holding up timely claim payment, including requests for medical records, coordination of benefit issues, and request for more information, by coordinating with the responsible department.

• Reviews remaining balances on accounts after insurance has paid to ensure the account was processed appropriately and performs the next appropriate action.

• Resolves overpaid accounts by performing payment review to determine if posting corrections are required or/and a refund is due to the insurance company.

• Processes incoming correspondence from insurance companies, and performs proper action utilizing internal and external resources.

• Maintains an account aging process for tracking accounts approaching 30 days past billing date.

• Processes adjustments or corrections to patient account(s) according to policy guidelines.

• Resolve denied claims utilizing the payer’s designated reconsideration and appeal process.

• Receives and resolves inquiries regarding accounts, either in-person, by phone or written correspondence from patients, family members, third-party payers, physicians, etc.

• Accurately and thoroughly documents all actions performed on an account in the appropriate area of the EHR system.

Credentialing:

• Performs initial insurance credentialing and re-credentialing activities for facilities and individual providers.

• Compiles and maintains current and accurate data for all providers and facilities required to complete insurance credentialing.

• Ensures data in CAQH is completed and kept up to date.

Mentorship:

• Assists staff in troubleshooting problems / issues, including assistance in monitoring their daily activities.

• Mentors staff on an individual basis to evaluate work tasks / processes and assists staff in developing efficient and effective processes.

• Maintains advanced knowledge of systems and billing requirements.  Serves as an educational resource to educate staff.

• Develops workflows and step by step documentation to assist in the training of staff.

Reporting:

• Reviews and acts on accounts receivable maintenance reporting.  Such as reporting on DNFB, claim edits, ATB, denials, clean claims, etc.

• Prepares reports to share with payers when discrepancies in reimbursement are uncovered.

Other:

• Maintains and reviews proper payer setup including but not limited to payer address, payer product lines, timely filing guidelines, submission schedules, ANSI codes and fee schedules

• Maintains current knowledge of billing and reimbursement rules as designated by the Centers of Medicare and Medicaid Services (CMS), Medicaid Managed Care, and other payers. Communicates all changes to applicable staff/departments/facilities.

• Maintains advanced reimbursement knowledge and performs reimbursement analysis as necessary. Monitors third-party contract payment arrangements, both private and governmental to ensure accurate reimbursement.

• Keeps up to date with regulations that affect collection of receivables; monitors third-party contract payment arrangements, both private and governmental. 

• Maintains proficient knowledge of EHR, clearinghouse, and payer systems, as well as any other systems, required for performing required job duties.

• Communicates issues to management, including payer, system, or escalated account issues.

• Maintains proficient knowledge of EHR, clearinghouse, and payer systems, as well as any other systems, required for performing required job duties.

• Participates in department meetings, in-service programs, and continuing education programs.

• Maintains a professional attitude with patients, visitors, physicians, office staff and hospital personnel.  Assures confidentiality of patient and hospital information, maintaining compliance with policies and procedures.

• Other duties as assigned.

• Demonstrates competency annually in assigned areas of work.