Summary:

The Billing Specialist is responsible for resolving claim edits for payors using the knowledge of the appropriate billing form and billing guidelines as well as various insurance contracts and payment methodologies to ensure a compliant claim. Reviews the claims to confirm the correct insurance filling order to ensure the correct payment at the time of initial submission. Ensures compliant billing based on the Office of Inspector General (OIG), CMS, HIPPA and any specific payor regulation. Proactively works accounts to maximize accurate and timely submission of claims utilizing knowledge of all billing guidelines.

Responsibilities:

Enters all Recovery Audit Contractor (RAC) reviews into the third-party software. Requests medical records and coordinates the response to the RAC request

for Hospital billingRequests and submits appropriate medical records to selected insurance companies or Medicare either for initial billing requirements or to respond to Additional Documentation. Requests (ADR) for oncology services. Works with audit nurses on coordination of medical records and letter of medical necessity for a formal appeal
for Hospital billing.

Resolves payor gateway rejections using payor systems (EDI) information and analysis of the claim issue

for Hospital billing.

Resolves error in claim edit work queues for accurate and timely submission of paper and/or electronic claims. Uses OIG, CMS and HIPPA guidelines to refer a claim to the appropriate department for review and resolution of the errors, as needed.

Resolves edits in charge review/charge router work queues to ensure complaint billing based on medical documentation

for Physician Billing.

Works in appropriate claim system for Medicare and Medicaid to resolve overpayments by the payor by updating claim information in their system.

for Hospital billing.

Creates and submits Part B only claim to Medicare for inpatient services when Medicare Part A benefits are exhausted. If another insurance is also available for billing, reviews and submits a claim for the non-covered Part A services to that payor for payment

for Hospital billing.

Confirms and corrects patient insurance information by calling the guarantor and/or mail inquires for accident insurance, workman's comp, or other needed insurance information. Updates account with any discovered insurance and notates the account with the new insurance information. Applies the unsolicited 271 transaction to add the insurance to the account, when applicable. Applies the unsolicited 271 transaction to add the insurance, when applicable

for Hospital billing.

Documents all billing activities in patient account record to accurately reflect what changes have been made to the claim/or insurance information. Identifies billing errors trends and directs these trends to management for review and/or resolution.

Resolves claims edits monthly for skilled nursing/long term care for accurate and timely submission of paper and/or electronic claims

for Hospital billing.

Reviews coding to ensure that the procedures coded are billable according to the regulations set by the different payors. Adds applicable billing modifiers, when needed. Resolves clearinghouse errors and resubmits the claim for processing. Bills secondary or tertiary insurance by interpreting the explanation of benefits (EOB) from the payor. Adjusts or bills late charge/credit replacement claims using insurance payment methodologies.

Competencies:

ACCOUNTABILITY, ACCURACY, ANALYSIS AND DECISION MAKING, BILLING, CUSTOMER SERVICE, PROBLEM SOLVING, RESPONDING TO CHANGE, STANDARDS OF BEHAVIOR

Education and Certification Requirements:

High School Diploma or Equivalent (Required)

Additional Job Information:

Complexity of Work:

Requires excellent communication skills, critical thinking skills, decisive judgment and the ability to work with minimal supervision. Knowledge of UB-04 and/or

CMS 1500

form, billing guidelines, insurance contract and payment methodologies. Must be able to work in a stressful environment and take appropriate action.

Required Work Experience:

No prior experience required. For Hospital Billing, the knowledge of UB-04 and EPIC hospital billing experience preferred. For Physician Billing, the knowledge of CMS 1500 and EPIC professional billing experience preferred.

Working Conditions and Physical Requirements:

Bending and Stooping = 0% Climbing = 0% Keyboard Entry = 80% Kneeling = 0% Lifting/Carrying Patients 35 Pounds or Greater = 0% Lifting or Carrying 0

25 lbs Non-Patient = 60% Lifting or Carrying 2501 lbs
75 lbs Non-Patient = 0% Lifting or Carrying > 75 lbs Non-Patient = 0% Pushing or Pulling 0
25 lbs Non-Patient = 60% Pushing or Pulling 26
75 lbs Non-Patient = 0% Pushing or Pulling > 75 lbs Non-Patient = 0% Reaching = 0% Repetitive Movement Foot/Leg = 0% Repetitive Movement Hand/Arm = 80% Running = 0% Sitting = 80% Squatting = 0% Standing = 80% Walking = 80% Audible Speech = 80% Hearing Acuity = 80% Smelling Acuity = 0% Taste Discrimination = 0% Depth Perception = 80% Distinguish Color = 0% Seeing
Far = 80% Seeing
Near = 80% Bio hazardous Waste = 0% Biological Hazards
Respiratory = 0% Biological Hazards
Skin or Ingestion = 0% Blood and/or Bodily Fluids = 0% Communicable Diseases and/or Pathogens = 0% Asbestos = 0% Cytotoxic Chemicals = 0% Dust = 0% Gas/Vapors/Fumes = 0% Hazardous Chemicals = 0% Hazardous Medication = 0% Latex = 0% Computer Monitor = 80% Domestic Animals = 0% Extreme Heat/Cold = 0% Fire Risk = 0% Hazardous Noise = 0% Heating Devices = 0% Hypoxia = 0% Laser/High Intensity Lights = 0% Magnetic Fields = 0% Moving Mechanical Parts = 0% Needles/Sharp Objects = 0% Potential Electric Shock = 0% Potential for Physical Assault = 0% Radiation = 0% Sudden Decompression During Flights = 0% Unprotected Heights = 0% Wet or Slippery Surfaces = 0%

Shift:

Primarily for office workers

not eligible for shift differential

Disclaimer:

This job description is not intended, nor should it be construed to be an exhaustive list of all responsibilities, skills, efforts or working conditions associated with the job. It is intended to indicate the general nature and level of work performed by employees within this classification. Wages shown on independent job boards reflect market averages, not specific to any employer. We encourage candidates to talk to their Memorial Healthcare System recruiter to discuss actual pay rates, during the hiring process. Memorial Healthcare System is proud to be an equal opportunity employer committed to workplace diversity. Memorial Healthcare System recruits, hires and promotes qualified candidates for employment opportunities without regard to race, color, age, religion, gender, sexual orientation, national origin, veteran status, disability, genetic information, or any factor prohibited by law. We are proud to offer Veteran's Preference to former military, reservists and military spouses (including widows and widowers). You must indicate your status on your application to take advantage of this program. Employment is subject to post offer, pre-placement assessment, including drug testing. 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