Overview
Responsible for obtaining appropriate reimbursement for Accounts Receivables for professional services of patients seen
in physician offices, out-patient hospital, in-patient hospital, ASC, urgent care, ER, off-site hospitals and Telehealth
locations while maintaining timely claims submissions. Registers patients and completes necessary documentation
including insurance verification and benefits determination. Research charges to submit to appropriate carrier according to
Federal/Managed Care rules, regulations and compliance guidelines. Review codes using CPT, ICD10, HCPCS and CCI
guidelines to ensure compliance with institutional compliance policies for coding and claim submission. Enter and bill
professional charges into automated billing system program. Utilize resources and tools in the resolution of invoices
following company policy for assigned payor/s. Resolving outstanding balances with internal and external communication
with customers.
Responsibilities
Triage invoices and determine appropriate action and
complete the process required to obtain reimbursement for all
types of professional services by physicians and nonphysician
providers maintaining timely claims submissions
and timely Appeals processes as defined by individual
payors.
Resubmit insurance claims when necessary to the
appropriate carrier based on each payor's specific process
with the knowledge of timelines.
Research, respond and take necessary action to resolve
inquiries from PSRs (Patient Service Reps), Cash
Department, Charge Review and Refund Department
requests. Follow-up via professional emails to ensure timely
resolution of issues
Must be comfortable and knowledgeable speaking with
payors regarding procedure and diagnosis relationships,
billing rules, payment variances and have the ability to
assertively and professionally set the expectation for review
or change.
Review, research and facilitate the correction of insurance
denials, charge posting and payment posting errors.
Follow all Managed Care guidelines using the UFJPI Payor
Claims Matrix and Managed Care Matrix for each contracted
plan
Identify and enter affected invoices on the MES (Monthly
Escalation Spreadsheet) using Excel, ESM or separate
spreadsheets that may be needed
Inform Team Leader on the status of work and unresolved
issues. Alert Team Leader of backlogs or issues requiring
immediate attention
Identify trended denials and report to supervisor, exporttrended/unpaid invoices on Excel t to track and provide to
supervisor
Must be knowledgeable of specialized billing, i.e. contracts
and grants
Perform special projects assigned by the Team Leader or
Manager
Verify completeness of registration information. Add and/or
update as needed. Verify and/or assign insurance plan and
code appropriately. Verify and enter patient demographic
information utilizing automated billing system. Verify
insurance coverage utilizing various online software tools.
Ability to work overtime as needed based on the needs of the
business
Complete correspondence inquiries from payors, patients
and/or clinics to provide the needed information for claims
resolution. This can include medical record requests,
determining if other health insurance coverage exists, auth
requirements, questionnaires, research of the documentation
and accounts, communicate with the clinics for additional
information needed, collaborate with providers and other
departments to obtain necessary information.
Respond and send emails to all levels of management in the
Revenue Cycle Departments, Cash Posting Department,
Refunds Department, Managed Care, Referral Department,
Clinics and the CDQ Department to resolve coding and billing
issues. Maintain timely communication to ensure all
necessary action has been taken.
Documents notes in the automated billing system regarding
patient inquiries, conversations with insurance companies,
clinics, etc. for all actions.
Receive and make outbound calls, written or electronic
communications, navigate multiple web portals and websites
to insurance companies for status and resolution of
outstanding claims. Status appeals, reconsiderations and
denials.
Make outbound calls to patients to obtain correct insurance
information and demographics
Review and interpret electronic remits and EOB's to work
insurance denials to determine appropriate action needed.
Interpret front end rejections. Determine appropriate
insurance adjustments and obtain adjustment approvals as
outlined in the company policy.
Verify and/or assign key data elements for charge entry such
as, location codes, provider #'s, authorization #'s, referring
physician, CPT, ICD-10, etc.
Qualifications
Experence Requirements:5 years Health care experience in Medical Billing or related experience - required Proven ability to develop course work presentations. required Ability to apply adult learning methodology in trainingclasses/presentations - required Experience with medical systems - preferred. Knowledge of CPT and ICD Coding and Medical terminology of most current versions - requiredEducation:High School Diploma or GED equivalent - required Bachelors Healthcare, Finance, IT or Education - preferredCertification/Licensure:Certified Professional Coder (CPC) requiredAdditional Details:CPC Certification completed within 18 months of employment.Travel Required:Up to 10%Additional Duties:Additional duties as assigned may vary.