Medical Claims Billing Specialist

Department: Business Office

Hours: Fulltime (1.0 FTE) – Day Shift

Description:

Position Overview: The Medical Claims Billing Specialist for Floyd County Medical Center (FCMC) is responsible for the billing and claims process. This role ensures accurate submission of medical claims to insurance companies, government programs, and patients, while adhering to all regulatory and payer-specific guidelines, including Medicare and Medicaid. The specialist will handle billing for both facility and professional services, claims processing, and follow-up on denied or underpaid claims.

Duties and Responsibilities:

• Claims Submission & Processing:
  • Prepare and submit accurate claims for inpatient, outpatient, and professional services in accordance with Critical Access Hospital (CAH) and Rural Health Clinic (RHC) billing guidelines.
  • Ensure timely submission of claims to private insurance, Medicare, Medicaid, and other third-party payers.
  • Verify accuracy and completeness of patient demographic and insurance information before claims submission.
• Coding & Compliance:
  • Collaborate with coding specialists to ensure that diagnosis and procedure codes are accurate and appropriate for CAH and RHC services.
  • Maintain compliance with all federal, state, and local regulations regarding CAH and RHC billing, including adherence to Medicare/Medicaid cost reporting requirements.
  • Stay current with changes in billing codes (e.g., Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), the International Classification of Diseases, Tenth Revision (ICD-10) and payer policies.
• Denial Management & Follow-Up:
  • Investigate and resolve claim denials, rejections, or discrepancies.
  • Communicate with insurance providers and government payers to appeal underpaid or denied claims.
  • Conduct regular follow-up on outstanding claims to expedite payment.
• Patient Billing & Customer Service:
  • Manage patient billing inquiries related to CAH and RHC services.
  • Assist patients with understanding their insurance benefits, out-of-pocket costs, and financial assistance options.
  • Coordinate with the financial counseling department to ensure patients receive proper financial guidance.
• Team Collaboration:
  • Work closely with clinical staff, coding teams, and financial departments to ensure the billing process is streamlined and compliant.
  • Participate in billing department meetings and ongoing training to stay informed of changes in CAH and RHC reimbursement policies.

• Other:
• Assists in inventory and ordering of supplies and equipment.
• Assists in maintenance of safe, clean work environment.
• Assists with the general operation of the Business Office Department.
• Assumes other duties and responsibilities that are related and appropriate to the position and area. The above responsibilities are a general description of the level and nature of the work assigned to this classification and are not to be considered as all-inclusive.

Minimum Education and/or Experience Required:

• High school diploma or equivalent required; associate or bachelor’s degree in healthcare administration, business, or a related field preferred.
• Minimum two years of experience in medical billing, with specific experience in CAH and/or RHC settings preferred.
• Familiarity with Medicare and Medicaid billing and cost reporting requirements for CAH and RHC.

Additional Qualifications:

• Proficiency with medical billing software (e.g., Meditech or other Electronic Health Record (EHR) systems).
• Knowledge of coding systems (CPT, HCPCS, ICD-10) and payer-specific guidelines.
• Excellent customer service skills, including telephone etiquette.
• Excellent computer skills.
• Excellent oral and written communication skills required.
• Self-motivated.
• Must be able to read, write, comprehend, and verbally communicate in English fluently.
• Integrity and ability to work independently. Initiative to take on tasks without being told.
• Strong attention to detail and organizational skills.
• Adaptive to change, embraces change with optimism.
• Ability to problem solve, critically think.
• Ability to prioritize assignments and manage time efficiently.
• Ability to operate technologies and equipment associated with this position.
• Must have a service mindset and a commitment to continuous learning.
• Ability to operate technologies and equipment associated with this position.
• Ability to work outside of regularly scheduled hours if needed.
• Mandatory Reporter.

Licensure/Certification Required:

• None

Physical/Cognitive Requirements:

• Sit: Constant
• Stand: Occasionally
• Walk: Occasionally
• Lift:
  • 10 pounds Occasionally
  • 25 pounds: Occasionally
  • 50 pounds*: Never
  • 75 pounds*: Never
  • Greater than 100 pounds*: Never
• Carry:
  • 10 pounds: Occasionally
  • 25 pounds: Occasionally
  • 50 pounds*: Never
  • 75 pounds*: Never
  • Greater than 100 pounds*: Never
• Push/Pull:
  • 10 pounds: Occasionally
  • 25 pounds: Occasionally
  • 50 pounds*: Never
  • 75 pounds*: Never
  • Greater than 100 pounds*: Never
• Squat/Kneel/Crouch: Occasionally
• Climb: Never
• Balance: Never
• Twist: Frequent
• Bend/Stoop: Occasionally
• Crawl: Never
• Grasp/Grip: Frequent
• Talk: Constant
• Hear: Constant
• See: Constant

• Anything greater than 50 pounds- assist of two or more, or mechanical lift are required.

Environmental Factors:

• May be exposed to communicable diseases due to working in a health care environment.
• Works in a well-illuminated climate-controlled environment.
• Work environment is comfortable, with minimal exposure to physical hazards.
• Moderate noise level when machines/equipment in use but typically quiet environment.

Organizational Relationships:

Reports to: Director of Patient Financial Services/Revenue Cycle Coordinator

Employees supervised: None