SUMMARY

For governmental third-party payers including Medicare, Medicaid, Medi-Cal, Veterans' Campus, Tri-Care, County, and other governmental payers performs third party bill paper and electronic preparation, editing, and submission to payer, ensures accurate identification of expected reimbursement amounts. Calculates and posts adjustments and write-off transactions to patient accounts receivable, collection, unpaid account follow-up, patient account analysis, preparation of appeals, identification of over-payments, initiating and processing refund request to third party payers. Escalates recurring issues preventing the effective and efficient processes needed for goal attainment.

REQUIREMENTS

RESPONSIBILITIES AND DUTIES:

• Claims submission. Responsible for ensuring timely submission of governmental claims in billing editor. On a daily basis prepares and submits primary and secondary claims using the billing editor software to submit claims electronically or hardcopy, ensuring all edits are worked in a compliant manner based on directives given by management.
• Account follow-up. Responsible for collection of unpaid or partially paid accounts by utilizing ATB reports, review of EOB’s and correspondence received from payers and taking appropriate action to resolve any issues and secure correct payment due including timely filing of appeals.
• Identification of accurate efficient reimbursement amount & posting appropriate adjustments as required.
• Identification of over-payments. Initiating and processing refund requests to third party payers in compliance with governmental regulations.
• Coding and charging errors. Ensures all charge and coding related issues are clearly identified & resolved or entered on the appropriate HIM/Charge audit spreadsheet for correction/resolution by appropriate department representation.
• Assists and successfully completes time sensitive projects as it relates to outstanding accounts receivables within the time frame stated by management.
• Maintains productivity levels within guidelines established by management. Receives an at or above team average productivity score.
• Documents clearly and succinctly in account notes all action taken on account. i.e. phone numbers, representative’s name, call reference number, corrective action taken, referrals made and specific claim submission details as appropriate.
• Performs duties with little or no errors. Remains at or above team average quality of work errors.
• Other duties as assigned.

EDUCATION & EXPERIENCE REQUIREMENTS:

• Some college preferred.
• 2 years’ experience in a medical office or hospital setting.

SKILLS & ABILITIES REQUIREMENTS:

• Knowledge of CPT, HCPC’s, HIPAA, Compliance and Regulatory issues.
• Knowledge of billing systems and software applications

PHYSICAL REQUIREMENTS:

• Body Positions: Sitting and standing for prolonged periods.

• Body Movements: Arm and hand dexterity.

• Body Senses: Must have command of close and distant sight, color perception and hearing.

• Strength: Ability to lift and move up to 25-pounds.