Billing Specialist

1.

Knowledge of health insurance programs, coverage offered and third-party reimbursement mechanisms, including Medicare, Medi-Cal, PPO, HMO, IPA, PMG, Military and Veteran

2.

Knowledge of Payer/Provider portals; verifying patient eligibility and covered benefits.

3.

Knowledge of adjustment codes, remark codes and denial reasons.

4.

Knowledge of ICD-10, CPT and HCPCS coding systems.

5.

Knowledge of electronic claims filing through Practice Management software, claims submission and 837 file review and trouble shooting through clearinghouse.

1.

Prepares and submits clean claims to various insurance companies either electronically or by paper.

2.

Verifies appropriate documentation of billable services on each claim according to specific payer requirements in an effort to minimize rejections and denials

3.

Ensure completion of documentation and coding on charges entered in patients accounts for a correct and complete billing claim.

4.

Researches, corrects and re-bills denied claims. Accurately and efficiently processes request for denied claims information using website portals and outbound phone calls for all Commercial, Medicare and Medicaid (Medi-Cal) insurance payers

5.

Follows up with insurance company and/or clearinghouse on unpaid or rejected claims. Resolves issue and re-submits claims.

6.

Prepares appeal letters to insurance carrier when not in agreement with claim denial. Collect necessary information to accompany appeal. 

7.

Refer to payer’s contract, Provider Manual and/or Billing Manual/Procedures as needed to confirm billing requirements, appeal procedures, etc.

8.

Review and submit medical records and other documentation- to ensure services meet required insurance standards and to respond to insurance medical record requests in a timely manner.

9.

Prepares and submits secondary and tertiary claims upon processing by primary insurer, according to payer requirements.

10.

Daily collections - obtaining status through insurance representatives (and online resources), maintaining schedule of each policy reimbursement to ensure uniform and highest paying reimbursement

11.

Assists in the completion of mandatory reports and special billing projects at the direction of the Revenue Cycle Manager.

12.

Works with clinic and finance staff to provide accurate assignment of patient services revenue into all clinic sites and programs.

13.

Ensures the accurate distribution and posting of all patient services revenue to correct sites and programs in the Electronic Health Record.

14.

Prepares patient statements for charges not covered by insurance. Ensures statements are mailed according to policies and procedures.

15.

Provides billing training and on-going billing support to new clinical staff and Patient Service Representatives, as needed.

16.

Assures that any adjustments and write-offs to accounts are done according to office policy and procedure.

17.

Follow Federal, State and local protocols, procedures, and billing guidelines

18.

Keeps current on all updates for state and local programs and other payer requirements by reviewing daily/monthly newsletters and bulletins

19.

Other duties as assigned.